Many hospitals around the nation have been stung by dreadful physician engagement scores. Engagement is a problem not only for demoralized physicians, but for healthcare organizations, their employees, and everyone they serve. They should take note, because low levels of engagement are associated with higher physician turnover, increased error rates, poorer rates of patient cooperation in treatment, and lower levels of patient satisfaction.
Definitions of engagement vary, but it generally includes pride, loyalty, and commitment. When engagement scores are low, physicians take little pride in the hospital, would not recommend it to a job-seeking colleague, and believe that the hospital’s mission and vision are not in sync the needs of patients. On the other hand, engaged physicians are more likely to perform better in every area, including patient care, education, and research, which benefits everyone.
To better understand the roots of poor physician engagement, I recently sat down for a conversation with a large group of students from the Indiana University Kelley Business of Medicine MBA program. Its students are practicing physicians from around the country who have realized that to improve patient care they need to become better leaders. Many work in hospitals that have identified engagement challenges and are attempting to develop solutions to the problem.
Challenged to explain declining physician engagement scores, the group pointed first to a lack of transparency. Many hospitals, they said, collect a great deal of information about the performance of their medical staff, but share little information in return. One physician described the situation in terms of a “one-way mirror,” in which data on physician performance are widely circulated, but the performance of the organization and its non-physician leaders remains largely opaque.
Another key problem, according to the group, is the fact that so many hospital administrators do not take care of patients. In contrast to physicians and nurses, whose work revolves around patients, hospital administrators typically have business backgrounds. Even health professionals who play leadership roles often “haven’t cared for patient in years,” said one participant. “This makes it difficult for them to understand what medicine is like on the front lines, and they seem out of touch.”
The group also pointed to the different standards by which physicians and hospital administrators are evaluated. The most important criteria of physician performance naturally revolve around patient care, while administrators are typically judged first on financial performance. This misalignment can frustrate both sides – physicians feel that administrators care about nothing but money, and administrators feel that physicians don’t understand the system-wide challenges the hospital faces.
Said one participant, “For many occupants of the hospital C-suite, the central operating principle is, ‘No margin, no mission.’ This means that, no matter how noble the hospital’s mission statement, revenue must exceed costs or the hospital will close. In too many cases, though, ‘No margin, no mission’gets transformed into, ‘The margin is the mission.’” Financial priorities begin to take precedence over why the organization exists in the first place – to care for patients.
The group pointed to the growing bureaucratization of healthcare, driven in part by consolidation among healthcare organizations. As hospital systems grow, their decision makingtends to rely more on impersonal policies and procedures and less on relationships. Said one participant, “This is frustrating to health professionals,whose careers are devoted tobuilding trust.” Many fondly recall a day when decision was based more on relationships than on policy and procedure manuals.
Another participant added, “To a hospital administrator, the corporation’s annual report might seem the most important thing, and the center of the universe might appear to be the hospital executive suite. But to health professionals, it is patients. When administrators put their own programs first, they inevitably seem out of touch with reality.” This can be especially frustrating when administrators come and go in just a few years, while many physicians maintain much longer commitments.
The physician-MBAs offered a number of suggestions for improvement. One is for hospitals to start treating health professionals as partners in care. This means, among other things, ensuring that decision making involves strong representation by physicians, nurses, and others who care for patients on a day-to-day basis. When they are not present, even seemingly well thought-out initiatives can prove dangerously at odds with patient care.
Another suggestion is to ensure that hospital boards are well populated with people who regularly care for patients. It is all well and good to have health professionals involved in daily tactical decision making, but if they are not also present when organizational priorities are set and strategies are crafted, a sense that organizational management is out of touch with reality is likely to arise. As one participant put it, “Would any law firm operate with a board comprised almost entirely of physicians?”
A third is to pair each administrator with a health professional who understands what day-to-day patient care is like. The goal here is to ensure that administration and health professionals work in partnership, not only during formal decision-making sessions such as board meetings, but throughout each work week. This is likely to produce a much higher level of mutual understanding, which is precisely what many physicians think is lacking at the moment.
The ultimate goal here is not to make physicians and other health professionals happier, but to take better care of patients. Said one participant, “Physician engagement isn’t just about whether doctors happen to be happy or not. It’s about integrity. It does no good for the hospitalto make lots of money and reward its executives handsomely if the people who care for patients distrust it. Improving engagement scores is ultimately about ensuring that health professionals believe in their work.”
Richard Gunderman is a professor of radiology at Indiana University and a contributing writer at The Atlantic.
Provider based billing (PBB) emerged in 2002 and launched massive consolidation through hospital system purchase of physician practices, turning physicians from owners to employees. While other legislative initiatives have helped to fundamentally change the landscape of how care is prioritized, supported, and delivered, PBB stands out as one of the more significant. Very quickly global billing revenue became inadequate to support the delivery needs of running a physician owned practice. But hospitals could acquire the practice, convert the program to that of a hospital department, and generate significant margins otherwise unattainable yet deliver the same or even less efficient service. The competitive landscape changed overnight and one by one, practices were sold. Understanding this history is an important to understanding some of the issues behind physician engagement. Younger physicians seem less affected and it would be beneficial to know how the engagement scores differ by years of practice?
As a practicing physician, and someone with expertise in the patient engagement space, I agree with Dike that the quadruple aim (long overlooked), is critical to physician engagement. Physicians typically have less time and more on their plates than in years past, and many feel as though they are on hamster wheels. C-suites at hospitals must recognize that if this cycle continues, physicians will feel less and less engaged.
In addition, physicians, just like the rest of us, want to feel appreciated for what they do well. When this comes from administration or from patients, a physician is much more likely to engage.
In our line of work in patient engagement, we measure engagement as a continuous parameter, much like a vital sign. When engagement is low, it poses a call to action to intervene.
It helps to set the framework for the word “engagement”. As originally defined by Christina Maslach and her team, engagement occupies the opposite end of a spectrum from burnout. The dismal engagement scores you see are a different way to look at the very high burnout scores among physicians.
In my work with thousands of burned out doctors, I can tell you that burnout is systemic, multifactorial and the factors you cite above lie in only one of the five major areas of stress that cause burnout and Dis-engagement. Some additional components of a burnout prevention/physician engagement strategy … and you are looking for a STRATEGY here not some magical SOLUTION. You can’t solve burnout or engagement … they are both dilemmas which require a sustained and detailed strategy to hit your goals.
– Quadruple Aim Mission Statement – so the health of the providers is in the company mission
– Training to provide personal tools for stress management, life balance and burnout prevention
– CQI activities designed to lower workplace stress
– and yes, administrative dyads at all levels – matching a physician and non-physician from the level of office manager on up
These are just a start. Here is what you don’t want to do.
– Spend a million dollars on a third party engagement survey
– Send that same 140 item survey to your doctors (what signal does that send, 140 questions … what are you thinking?)
– Then fail to share the results with your people because they are so bad
I see a half a dozen organizations make this mistake every year. It is a behavior pattern your people are watching and it sends a massive cultural signal that leadership is clueless.
We teach over 117 ways to prevent burnout and create engagement. Just sayin’
Dike Drummond MD
CEO and Founder
Appreciate the insights, Dr. Gunderman.
I suspect it must be exceptionally frustrating to be a physician at this juncture, and I can see the value of your solutions (if implemented well) in terms of making treating MDs feel more respected.
Curious – can you point me to any particular data sources or reports on declining MD engagement?
I’d be curious as to what factors correlate with higher / lower satisfaction. I.e. are there differences between specialists / PCPs? Physician age? Size/type of institution (i.e. IDN vs. stand-alone academic hospital vs. stand-alone community hospital)? Regional factors? Incentives that are based solely on RVUs vs. other forms of incentivization?
I have to imagine that there are a lot of either factors that could be parsed out that might suggest steps that could be taken, and I’d simply be fascinated to see it.