Engagement: Insights from the Front Lines

In 2007, the institute for healthcare Improvement introduced the framework of the Triple Aim. As envisioned by the IHI, optimal health care addresses three key elements simultaneously: it improves the patient care experience, it improves the health of a population, and it reduces per-capita health care costs.(1)

Since the Triple Aim was conceived, another facet of care has risen to prominence for its influence on organizations seeking to fulfill the Triple Aim: raising the joy in work. Derek Feeley, the institute’s president and CEO, emphasized that staff burnout has a direct negative impact on patient experience. Although achieving the Triple Aim continues to be a focus of the IHI and other organizations, Feeley endorses paying attention to the wellness of those providing care. Increased stresses on the health care system affect those at the front line of care,(2) particularly physicians.(3-5) These stresses affect physician burnout, which, in turn, affects engagement.(6)

Challenges Faced

Enloe Medical Center is a 298-bed, independent, not-for-profit, Level II trauma center in rural northern California. In 2006, the organization experienced significant challenges that required reimagining the leadership model and increased investment in physician leadership development,(7,8) because physician engagement is “the holy grail of today’s healthcare industry.”(9) Since 2009, Enloe has conducted periodic physician-engagement surveys using an instrument developed by Gallup, the American research organization (see Figure 1).

Figure 1. Overall medical-staff engagement, 2009-17

In 2015, Gallup measured physician engagement with its CE tool,(10) which is used to measure customer engagement in other settings. It assessed physicians’ connection to the organization using eight emotional attachment and three rational loyalty questions.(11) In 2017, Gallup refined it into the CE3 metric, which describes engagement as a measure of confidence, pride and partnership.(11) Gallup’s internal validation confirmed that CE3 survey results directly aligned with those obtained using its previous CE11 tool, an 11-question assessment.

Based on the 2009 survey, overall medical staff engagement ranked nationally at the 44th percentile. Three years earlier, having just embarked on a major construction project and an affiliation with the patient-centered Planetree organization, contract negotiations collapsed between administration and an exclusive-contract physician group. Turmoil resulted in the resignations of the CEO, board chair and board vice chair. Subsequent quality disruptions shattered the confidence of the community and the organization. In 2009, after three years of transition and stabilization, the organization selected a new CEO, who helped create a new patient-centered, values-driven mission and vision.

The 2017 survey demonstrated physician engagement at the 85th percentile when compared to the Gallup national database. In that survey, nine of the 15 departments showed engagement scores considered “best practice” (greater than or equal to 75th percentile), ranging from the 1st to the 99th percentile. Consultants characterized the 2015 results as showing “polarization,” whereas the 2017 results demonstrated “teamwork” (see Figure 2).

Figure 2. Physician engagement by department, 2015-17

Many variables were stable from 2015 to 2017. Nursing turnover was less than 7 percent. No major infrastructure or service-line changes occurred. Senior leadership was unchanged. The hospital posted a modest positive margin in fiscal years 2015-17. Hospital volumes increased approximately 7 percent the fiscal year before the 2017 survey. The Hospital Consumer Assessment of Healthcare Providers and Systems response to “overall rating” remained above the 75th percentile.

Questions Raised

Compared to 2015 results, 2017 engagement trended toward the upper percentiles. This observation led to the question posed by this study: What do physician leaders believe contributes to higher engagement scores? Published literature most often posits factors that might lead to higher engagement.(12,13,14) Other studies shared techniques enacted to improve engagement.(6) This study adds to current knowledge by reporting physician leaders’ own insights into the strategies they see and use to improve physician engagement.

I interviewed 21 medical staff leaders representing 18 specialties across the 15 medical staff departments. Of these leaders, 12 were medical directors with current or past department chair experience, five were current or past department chairs, three were medical directors without department chair experience, and one was an informally influential physician leader. I reviewed the engagement survey results, previously shared with all departments, with the physician leaders before asking them three questions:

• What do you make of the engagement results?

• What do you do to engage physicians in your department?

• What should be done to maintain engagement?

I reviewed responses for common themes that, if implemented, might foster a culture of high physician engagement.

Results

Three domains contributed to high physician engagement: administration, physician group culture and physician leadership.

Administrative Domain

“Administration’s role is to create an environment that allows doctors to do their best and then let them do their best,” one medical director/department chair said.

C-suite culture: Physician engagement starts here. C-suite culture is most visible in the relationship between physicians and the CEO. Physician leaders frequently cited the CEO’s open-door management style as a strength that contributes to engagement. The CEO demonstrates the value placed on physicians by keeping commitments made to doctors, meeting with physicians in their offices and thanking them for their time, and carefully considering physician opinions in decision-making. Physician leaders said contract challenges were the main driver of low engagement.

Practice models: Responding to physician requests to relieve the burdens of running practices, administrators implemented a financial model that allows the hospital to contract with specialty physicians for professional services while the hospital owns the practice assets and manages the business. Building on experience with hospitalists and onsite trauma surgeons, administrators worked with physicians to create additional in-hospital practice models for neurology, cardiology, nephrology and pediatrics, with obstetrics under consideration. Physicians overwhelmingly described their experience with the new practice models as “win-win” and “fair.”

Recruiting: A physician leader said, “Having more doctors to be on call contributes to better engagement.” Administrators increased resources dedicated to recruiting, which resulted in more new physicians on staff. These new physicians relieved shortages in several practice areas, improving the quality of life in those specialties. Physician leaders cited this commitment to effective recruiting as a factor in reducing work stress and providing better work-life integration. These leaders also identified administrators’ willingness to hire locum tenens physicians to bridge the gap between recruitment and new physician start dates as an acknowledgement of the hard work physicians do.

Common space for physicians: Rosenthal and Verghese observed that “perhaps the greatest opportunity for improving our professional satisfaction in the short term lies in restoring our connections with one another.”(15) A physician leader identified the difficulties in maintaining collegial interactions, particularly between doctors of different specialties, as they become busier and general medical staff meetings are less well-attended.

Also, several years before the 2017 engagement survey, a new food service contract was put in place. Now, a chef is stationed in the cramped medical staff dining room weekday mornings, preparing fresh and made-to-order food. The physician lounge transformed from a sparsely visited room to a place to connect with colleagues on a professional and personal level. The CEO stated that the administrative suite, dating to the 1980s, would not be renovated until a new physician lounge was completed, demonstrating the priority placed on physician experience. Enloe completed the new physician suite, with a large dining area, library, and adjoining conference area, 18 months after the 2017 engagement survey.

Physician reception: Administrators host a yearly physician reception at a local point of interest where they introduce new physicians. Open to physicians and their guests, a physician leader stated that this reception contributed to a more engaged medical staff.

Physician Group Culture Domain

“Engagement is driven by group culture,” said one physician leader. This observation identified a key lesson from the data: Not only does the C-suite culture influence organizational success or failure, but physician group culture is central to those outcomes as well.

Work-life integration: Several departments promote extended periods of time off for physicians to use as they choose. Called “sabbaticals” by one department, physicians use this time for personal growth, work outside the country, and in-depth training at a university setting.

Social connectivity: In addition to department-based social events to celebrate holidays or harvest time, one department met for an afternoon of go-kart racing to build community. For decades, members of an off-campus department have walked to the hospital to eat lunch together.

Small groups: Journal clubs promote collegiality and intellectual growth. One medical director leads a journal club for physicians and advanced-practice professionals at different local restaurants, with the cost of meals paid by the administration. Another hosts monthly discussion groups focused on nonmedical topics to enrich participants’ lives.

Group leadership in the hospital: Because of the hospital’s geographic isolation, most physicians work only at one hospital. This exclusivity drives many to feel invested in the organization where they are building their careers. One hospital-based group asks each member to participate in a quality-improvement project every three years. Several groups set the expectation that members will serve on key hospital committees and those physicians report to the group during department meetings.

Using technology to connect: HIPAA-compliant technology, such as secure texting, facilitates physicians seeking to contact a colleague for input on difficult cases, which improves patient care and fosters a supportive environment among group members.

Physician Leadership Domain

“Medical director meetings and physician leadership retreats create a good sense of team,” said one medical director. All physicians interviewed had significant leadership experience. Of the 21 physicians interviewed, 15 were current medical directors, and all but one physician had current or past department chair experience.

Leadership development: Annually since 2001, medical directors and physician department chairs gather offsite for a leadership retreat, addressing topics such as peer review, quality improvement and burnout. The retreat establishes leadership priorities for the year. The CEO, chief medical officer, chief nursing officer and other senior hospital leaders and board of trustees members attend, sharing the cost between medical staff and administration. Since 2014, medical directors meet quarterly with the CMO, CEO and other senior leaders. These meetings establish medical directors as a distinct leadership body and allow direct input on topics of importance.

Collaboration and continuity: Historically, the chief of staff role was a solo endeavor. In 2008, the three medical-staff officers implemented monthly “cabinet meetings” with the CMO and director of medical staff services. In 2015, this group was expanded to include the CEO. In addition to reinforcing the importance of communication and collaboration between senior hospital and physician leaders, the cabinet meetings create a team-based physician leadership model and peer support for officers, as they face challenging situations.

Recognition: Since 2005, the medical executive committee selects a member of the medical staff to receive the annual Physician Legacy Award. One former department chair and recipient of this peer-selected award said this was “a highlight of [his] career.” Since 2008, a physician who consistently demonstrates patient-centered care is awarded the Spirit of Planetree Physician Champion Award. The administration transcribes positive comments about physicians, taken from patient surveys, and gives them to physicians at department meetings; comments are kept in physicians’ medical staff files. Quarterly “Stories of Excellence” reflect exceptional care throughout the organization, and physicians are often recognized in these vignettes.

Meeting culture: Hospital meetings begin with “moments of excellence.” The medical staff has adopted this practice to recognize “good stuff.” One department chair uses a “three-minute rule” to guide how long an individual can speak on a topic to allow everyone to participate and everyone to feel heard.

Leadership culture: The medical staff secretary-treasurer leads the annual Quality Summit, at which physician champions present outcomes of projects completed the prior year. This event highlights significant achievements that raise quality throughout the organization. Several physician leaders set the expectation that their department members participate on major hospital committees and report that work at department meetings. One physician leader sees her role as identifying what colleagues are passionate about and tapping them to get involved.

Discussion

I asked 21 physician leaders for their insights on what contributes to high physician engagement, measured by the Gallup Physician Engagement Survey. Those leaders identified actions and behaviors in three domains that are important to physician engagement (see Table 1).

Factors identified by physician leaders closely mirror important leadership behaviors shown to reduce burnout and promote engagement.(16,17) These factors also reflect elements of the Stanford Wellness Model,(18) which describes the reciprocity of a culture of wellness, practice efficiency and personal resilience on physician well-being.

The engagement survey instrument and the study setting presented limitations. The Gallup survey instrument measuring physician engagement changed from the CE11 (used before 2017) to the CE3 survey used in 2017. The Gallup organization provided the hospital a letter attesting to the direct comparability of the two survey instruments but that change raised questions when discussing the results, particularly with the board. The 2015 percentile-rankings results were converted to the corresponding percentile under the CE3 survey, allowing comparison of the 2015 and 2017 data. Study findings, conducted in an independent, nonprofit hospital, might not directly apply to more-complex systems, for-profit organizations or outpatient settings. The structure of the interviews, conducted in-person by the author, might have influenced the responses.

This small study was not designed to measure the statistical significance of the observations. It was intended to promote wisdom-sharing between a specific group of physician leaders and those at other organizations.

There are several suggested directions for further study. The medical directors comprise 15 percent of the active medical staff. When 10 percent of a population holds to a particular idea or belief, that idea or belief will spread more quickly.(19) Physician engagement represents particular beliefs about physician experiences in an organization. Further study might identify if the engagement of medical directors, which in 2017 reached the 96th percentile, can be used as an indicator of physician-hospital alignment. Figure 2 presents data worth further study — specifically, which factors contribute to engagement data that show the largest year-to-year changes.

Conclusions

Physician leaders in this independent, not-for-profit rural hospital identified actions and behaviors associated with high degrees of engagement. While not evaluated for statistical significance, the observations showed consistency around the important domains affecting physician engagement. These findings might be applicable to other physician leaders and organizations seeking to improve physician engagement.

References

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2. Feeley D. The Triple Aim or the Quadruple Aim? Four points to help set your strategy. Institute for Healthcare Improvement. http://www.ihi.org/communities/blogs/layouts/15/ihi/community/blog/itemview.aspx?List=81ca4a47-4ccd-4e9e-89d9-14d88ec59e8d&ID=63 . Published Nov. 28, 2017. Accessed Feb. 11, 2018.

3. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among physicians relative to the general US working population. Arch Intern Med. 2012;172(18):1377-85. doi:10.1001/archinternmed.2012.3199

4. Helfrich CD, Simonetti JA, Clinton WL, et al. The association of team-specific workload and staffing with odds of burnout among VA primary care members. J Gen Int Med. 2017;32:760-6. doi:10.1007/s11606-017-4011-4

5. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-60. doi:10.7326/M16-0961

6. Shanafelt T, Noseworthy J. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92:129-46. doi:10.1016/j.mayocp.2016.10.004

7. Nelson MF, Merriman CS, Magnusson PT, et al. Creating a physician-led quality imperative. Am J Med Qual. 2014;29:508-16. doi:10.1177/1062860613509683

8. Nelson M. From the 2nd percentile to the 75th percentile in four years. California Healthcare News. http://www.cahcnews.com/newsletters/ca-mnelson1011.pdf . Published Sept. 8, 2011. Accessed July 23, 2018.

9. Freed Associates. Developing a successful physician engagement strategy. Becker’s Hospital Review.https://www.beckershospitalreview.com/hospital-physician-relationships/developing-a-successful-physician-engagement-strategy.html . Published March 30, 2017. Accessed July 22, 2018.

10. Gallup Consulting. Turning customers into true believers. http://www.gallup.com/services/169331/customer-engagement.aspx . Published 2000. Accessed May 29, 2018.

11. Gallup Consulting. Customer engagement: What’s your engagement ratio? https://www.gallup.com/file/services/176297/Customer%20Engagement%20Ratio%20Brochure.pdf . Published 2009. Accessed May 29, 2018.

12. Mayer R. Quint Studer on physician engagement: Maximize your greatest resource. Physician Leadership News, from American Association for Physician Leadership. https://news.physicianleaders.org/quint-studer-on-physician-engagement-maximize-your-greatest-resource . Published Feb. 8, 2018. Accessed May 28, 2018.

13. Freed Associates. Developing a successful physician engagement strategy. Becker’s Hospital Review.https://www.beckershospitalreview.com/hospital-physician-relationships/developing-a-successful-physician-engagement-strategy.html . Published March 30, 2017. Accessed May 29, 2018.

14. Agency for Healthcare Research and Quality. Physician Engagement (Slide Presentation). Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/physengagement-slides/physengageslides.html . Updated June 2013. Accessed May 29, 2018.

15. Rosenthal DI, Verghese A. Meaning and the nature of physicians’ work. N Engl J Med 2016;375:1813-5. doi:10.1056/NEJMp1609055

16. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90:432-40. doi:10.1016/j.mayocp.2015.01.012

17. Shanafelt R, Swensen S. Leadership and physician burnout: Using the annual review to reduce burnout and promote engagement. Am J Med Qual. 2017;32:563-5. doi:10.1177/1062860617691605

18. Bohman B, Dyrbye L, Sinsky C, et al. Physician well-being: The reciprocity of practice efficiency, culture of wellness and personal resilience. NEJM Catalyst. https://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience . Published Aug. 7, 2017. Accessed July 2, 2018.

19. Xie J, Sreenivasan S, Korniss G, et al. Social consensus through the influence of committed minorities. Phys Rev E. 2011;84:1-8. doi:10.1103/PhysRev/E.84.011130