Engaging Physicians Matters: The What, Why, and How

Individual commitment to a group effort—that is what makes a team work, a company work, a society work, a civilization work.

—Vince Lombardi

The extraordinary circumstances imposed by the COVID-19 pandemic have made physician leadership and engagement a pressing priority as health systems, medical groups, and hospitals adapt and cope with healing and recovery and navigate increasing pressures from payers to shift to risk-based, performance-driven contracts.(1)

We define physician engagement as a commitment by physicians to advance the Quadruple Aim of a high-quality, low-cost patient experience and physician and staff experience within their organizations for mutual success.

Every health system and hospital wants physicians to be deeply engaged. However, defining what that means is a long-standing, complex, and difficult issue.(2-4) Hope springs eternal, to paraphrase Napoleon, that increased physician engagement will lead to an “easy button” in tackling the myriad issues that beset healthcare delivery.(5) A successful physician-led value transformation and healthcare delivery redesign is not possible with a “disengaged, disaffected, uncooperative medical staff.”(6)

But despite the near universal struggles of health systems to build on physician engagement, Perreira et al.(4) and Reinertsen et al.(7) found that none had made efforts to define, measure, plan, or improve medical engagement. Spurgeon et al.(5) state that leadership “remains subject to fashion and is therefore fickle in its manifestation.” And a history of bad relations or trust issues can derail any engagement attempts, because “physician memory of difficult hospital interactions is very long.”(7)

Physician engagement is critical when it comes to improving quality outcomes, improving patient safety, driving excellence, improving physician resiliency and satisfaction, and working toward personal and professional development.(2,4,6,8,9,10,11,12) Moreover, because physicians make decisions accounting for 87% of costs in healthcare,(10) their engagement is critical to lowering costs.(4,7,10,11,13)

Definition of Engagement

Pereira et al.(4) classify engagement at the micro level as occurring during individual patient encounters. At the macro level, that applies to system-level processes involving strategic planning and decision-making.(4)

Spurgeon et al.(13) say engagement is a “commitment to high quality care.” Spurgeon, Clark and Wathes(5) also elaborate: “engagement is the active and positive contribution of doctors, within their normal working roles, to maintaining and enhancing the performance of the organization, which itself recognizes this commitment, in supporting and encouraging high quality care.” This definition, in their opinion, highlights the give and get inherent in physician–administration compacts.(5) Scheepers et al.(9) note that engagement is “marked by motivational state of well-being, high levels of energy, enthusiasm and dedication to one’s work.”

Although there is no universal definition of engagement, many commonly used terms convey the idea, including effectiveness, active support, partnership, and team work. Improved organizational performance and workplace alignment, as well as accountability, are other words describing engagement. Relationships that nurture a sense of purpose and meaning,(4) appropriate use of hospital services, implementation of best practices, leadership development, enhanced communication, advocacy, research, and involvement in strategy, decision-making and care delivery(11) are other terms also noted often. Belief in one’s work and feeling committed to the work involved(12) and decreasing non–evidence-based variations in treatment(2) are other themes that weave themselves into definitions of engagement.

Based on our reading of all these definitions, we define physician engagement as a commitment by physicians to advance the Quadruple Aim of a high-quality, low-cost patient experience and physician and staff experience within their organizations for mutual success.

Discussion

Our organization, Lee Health, is a health system employed medical group of 784 physicians and providers. We have endeavored to engage physicians in a multitude of ways, all with the focus on developing a personal connection and relationship with the physician.

During onboarding and hiring, we, as the dyad leadership team of the organization, meet with all new physicians to discuss how they can be successful in the organization and to encourage them to become involved in areas of interest to them. The Chief Medical Officer also personally pens a one-page letter to each new physician to welcome him or her into the organization and follows up with a personal phone call within 30 to 90 days and again in six to nine months after the physician starts. The response to this outreach has been extraordinarily positive, and many physicians are both surprised and delighted by these personal contacts.

The dyad also engages with physicians by reaching out to them by phone or text to recognize extraordinary efforts or to provide encouragement in challenging times. Typically, each dyad leader reaches out to two or more physicians per week and makes a concerted effort to make these connections, including scheduling time on the calendar to be sure calls are made.

In addition to individual contacts, a multitude of venues allow the dyad team to connect with physicians. These include routine town halls, which are phone calls offered at multiple times for physicians to hear about what is going on within the health system. The dyad visits each practice location at least once annually for a listening tour that includes the physicians and staff to build relationships and understand the challenges the practice may be facing. There is a monthly newsletter; a quick two-page read, highlighting the work and progress of the physician group. An all-physician meeting is held quarterly, providing an opportunity for socializing and hearing from physicians in the group about the work they are doing. All of these interactions help advance our intent to communicate; involve; and build support, relationships, and connections between leadership and physicians.

In the Lee Physician Group, the Chief Medical Information Officer led a significant initiative in 2019-2020 to improve the EMR experience. An outside consultant interviewed physicians, and efficiency reports available from the EMR helped determine pain points and areas of inefficiency. Additionally, targeted education for physicians identified as spending an inordinate amount of time in the EMR was implemented. The improvement approach included system-wide EMR template changes to improve the workflow. A new educational program for all physicians and development of an EMR optimization team to support the physicians in the practices was introduced. In resurveying our physicians, 28 points out of the original 33 points were improved, and comments indicated very positive improvements.

A family medicine faculty physician led our efforts to improve social determinants of health as well as reduce health care disparities. This faculty member also created a Population Health Certificate Program to train other physicians and staff on how to incorporate population health techniques into their practice. By identifying an individual with passion for the work, and allowing dedicated time to pursue that interest, we made great progress in treating our most vulnerable populations.

The Lee Health and Lee Physician Group also rolled out the Exceptional Lee Promise, which was a collective commitment to personal and organizational excellenceIt included a promise to engage in active listening, connecting with patients and each other with empathy, compassion, and respect (Figure 1). The medical staff also adopted a Physician Compact that embraced principles of stewardship, excellence, teamwork, honesty, and respect (Figure 2).

Figure 1. The Exceptional Lee Promise offers a collective commitment to personal and organizational excellence. It includes a promise to engage in active listening and connecting with patients and each other with empathy, compassion, and respect.

Figure 2. The Lee Health Medical Staff Compact between leadership and physicians and advanced care providers embraces principles of stewardship, excellence, teamwork, honesty, and respect.

In an effort to bolster our physician and advanced provider leadership development, we have partnered with the American Association of Physician Leadership (AAPL) and Professional Research Consultants (PRC) to deliver high-quality physician and advanced provider education and engagement.

Lee Health also has a Physician/APP Resiliency Committee that meets often to make recommendations, based on physician and advanced practice provider (APP) feedback, on steps to mitigate stress and burnout.

The Lee Physician Group understands that medical staff engagement is a prerequisite for high performance. Every three years, we conduct a confidential survey to measure engagement of physicians and advanced practitioners and allow them to give voice to other areas about their career and working environment. Between the 2018 and 2021 studies, the Lee Physician Group showed a significant increase—two deciles— in the engagement index for physicians. APP engagement increased by 5%, but did not reach the statistically significant threshold. The employed group had a 55% survey return rate. Engagement scores were highest for the pediatric division and lowest for the primary care division. In response to the question about staying within our organization, 78% of physicians replied “no” to plans of leaving the organization and had high engagement scores, whereas the physicians who answered “yes” to considering leaving the organization had the lowest engagement scores. In the 2021 survey, 32% answered “yes” to feeling symptoms of burnout “sometimes” or “always,” and this group also had lower engagement scores, compared with those who said they “never” or “rarely” suffered any burnout symptoms. Of the other five broad categories on the survey—Leadership, Competitive Position, Quality, Care/Services, Diversity/Equity/Inclusivity—statistically significant gains were made between 2018 and 2021 in all categories for physicians and in three categories for APPs. Areas that showed the greatest improvement since our 2018 survey were as follows:

• Retaining talented physicians;

• Operating room turnover times;

• Physician opportunity to shape quality improvement initiatives;

• Lee Physician Group leadership doing a good job explaining decisions to physicians;

• Lee Physician Group leadership having a good understanding of the issues facing physicians;

• Lee Physician Group leadership making a real effort to gather input from physicians; and

• The direction of the Lee Physician Group creating excitement about its future.

Areas for improvement were identified in meaningful involvement opportunities for physicians in diversity/equity/inclusion initiatives, retention strategies aimed at stabilizing talented contributors, publicizing quality and patient care achievements, and focus on operating room services.

Engaging physicians is not a linear process but, rather, an evolving one. The process is not about making some structural changes in the system(14) but about embedding long cycles of change.(15) High levels of physician leadership and engagement often drive higher quality metrics indicators and patient safety among the best health systems, but there are few guidelines on how to harness physician expertise, clinical freedom, and status.(1,15) However, as Spurgeon(6) notes, this engagement is not spontaneous, and organizations need to invest in its development. Nurturing physician engagement is a time-consuming process that needs multiple planned activities and initiatives to help drive a cultural shift but also embrace the interdependence of administrators and physician leaders.

In looking at demographic factors, Perreira et al.(11) reported that younger physicians and experienced physicians show highest engagement, as do male psychiatrists and single physicians. Their study also noted that higher emotional intelligence and purpose correlated with better engagement. From a system perspective, the ability to combine nonclinical tasks such as teaching, research, and so forth had better engagement, whereas job demands, overtime, work overload, and emotionally charged environments had a negative impact on engagement.

The complex journey toward more and better physician partnership can be difficult, and requires a good understanding of the existing state of relationships before moving toward a new culture.(7) The attempt to engage physicians requires competencies in people skills, process improvement, harnessing technology, clinical expertise, and tenacious follow-up.(9,16)

A hospital medical staff does not have a single culture but, instead, several microcultures corresponding to departments, medical groups, subspecialties, and so on.(7) Reinertsen et al.(7) wrote that the goal in physician engagement is to get each physician to move to the highest levels of self-actualization per Maslow.

Current advocacy of physician engagement and leadership involves improvement in a system redesign of healthcare delivery, not just advancing the practice of individual professionals.(13,14)

Davies, Powell, and Rushmer(3) listed ten key issues that complicate engagement. Among these were poor agreement among groups about definitions of quality or good practice, lack of data transparency and data weaponization, poor dyad partnerships, physician concerns regarding encroachment on their autonomy, and time constraints. They also found that clinicians’ approaches to quality initiatives ranged “from apathy to outright resistance.” Taitz et al.(2) also noted that time, existing culture, need for clinical freedom, lack of training and skills in continuous quality improvement (CQI), and cost considerations are most often cited as barriers to effective physician engagement. Denis et al.(15) note that health systems need to drive toward organized professionalism, where transactional relations based on monetary needs are replaced by transformative cultural changes. They postulate a need for influencing three broad and distinct types of institutional logic:

• Professional logic: relating to self-regulation and clinical freedom;

• Organizational logic: relating to implementing best practices around management and CQI; and

• Policy logic: relating to mandates dictated by external agencies (regulatory and governance).

Fostering physician engagement(4) should address accountability, performance, and CQI, with attention to cost of care. Communication among physicians and between hospital administrators and physicians should be addressed; use of communication boards should be considered(5); and valid, reliable data should be shared transparently.(4,15)

Lee and Cosgrove(17) argue for a move from a physician-centric model to a patient-centric mode. They encourage leaders to be ready to hold clinicians accountable to team-based concepts, which focus on outcomes and efficiency. Their model uses Max Weber’s framework of “creating a shared purpose, self-interest, respect and tradition.” They stress the need to set expectations around creating value for patients, highlighting the need to make sacrifices, listening to myriad views and—by shedding light on patient stories—helping drive engagement. Using examples of the Mayo Clinic’s “needs of the patient come first” and Group Health Cooperative’s “transform healthcare by working together,” they highlight this “focus on patients, status quo being inadequate and group action needed to pursue shared goal.”(17)

Ascension Health, one of the largest nonprofit Catholic private healthcare systems in the United States, launched an initially much-resisted initiative in 2006: a full disclosure system to acknowledge medical errors. Their effectiveness in improving disclosure rates of medical errors relied on using the motivational levers (Max Weber) of shared purpose, highlighting ethical care, liability insurance discounts, respect by peer pressure, and requiring physicians to consult with event response teams; this allowed them to change the disclosure rate to 24% in three months, to 41% in one year, and to 57% in 27 months.(17)

The complex and difficult arena of physician engagement calls for novel and flexible options(16) (see sidebar).

The tenets common to most physician engagement strategies rely on robust communication methods, physician compacts that drive a shared vision, teamwork, physician education and training, data governance, addressing physician resiliency and burnout, and recognizing physician contributions.(1,4,6,7,8,15,17,18)

Two systems that have successful medical leadership and engagement are the Danish system and Kaiser Permanente. The Danish system mandates that a doctor be on the management board of every hospital. In that system, clinicians dominate leadership management positions.(15) Kaiser Permanente, using dyads, has managed to reduce conflicting priorities and implemented a robust management training program for physicians.(15)

Denis et al.(15) recommend designating physicians as champions for specific clinical conditions to advance delivery of high-quality care.

Paulus, Davis, and Steele(19) at Geisinger Health System found that “engagement can be fostered where supportive information, technology and incentives exist, where physicians participate in the design of key system features and where there are clear performance and/or improvement targets.”(19)

Measuring engagement rates among physicians is an important principle in physician engagement. Spurgeon et al.(12) recommend two types of metrics so the tool can assess three types of engagement for individuals and organizations. Organizational opportunity scales reflect the cultural conditions that facilitate doctors becoming more actively involved in leadership and management activities. Individual capacity scales reflect perceptions of enhanced personal empowerment, confidence in tackling new challenges, and increased self-efficacy. Their measurement tool allows for answers to questions around engagement as seen through the lens of relationships, involvement, and motivation.(2) This newly developed medical engagement scale has 18 to 30 items and can provide an overall index of engagement together with an engagement score on reliable meta-scales:

• Metascale 1: feeling valued and empowered (working in an open culture);

• Metascale 2: having purpose and direction; and

• Metascale 3: working in an open culture (feeling valued and empowered).

This scale, available through the NHS Institute for Innovation and Improvement, was developed using a very large sample of over 20,000 NHS professionals and used reliable, valid data.(12) Success in using the tool assumes a high level of motivation and commitment on the part of physicians across the healthcare continuum.(5)

Options for periodic physician engagement surveys include using an instrument developed by Gallup, the American research organization, or Gallagher, among others that provide for similar survey analyses.

Other researchers(8) have suggested using surrogate markers to monitor engagement, such as first-year turnover, sick time utilization, workplace injury rates, hand-hygiene compliance, and engagement survey participation. One could also consider using quality scores and shared savings as other metrics to track and trend engagement.

The Physician Engagement Difficulty Assessment(7) is intended to provide a rough assessment of the cultural and historical factors that need to be taken into account when building a physician engagement plan. This tool includes scoring on physician connectedness, physician loyalty, stability of medical staff structures, mergers and relationships, currency of medical staff bylaws, Medical Executive Committee authority, board engagement with medical staff in QI initiatives, and historic cultural engagement.

Regardless of the choice of measurement tool, it is vitally important to have a process in place to monitor and pulse-check the levels of physician engagement. Trend lines and troughs can quickly alert one to a derailment of physician engagement and allow for corrective steps.

Conclusion

It is vital to be deliberate and forceful in formulating a well-defined cultural change in engaging physicians.(5) As Berwick and Nolan(20) said, “Nothing about medical school prepares a physician to take a leadership role with regard to changes in the system of care. Physicians are taught to do their very best within the system and to perfect themselves as individual professionals by advancing their skills and knowledge every day. However, being a better physician and making a system better are not the same job. They require analogous but somewhat different skills.”

With an engaged, trained, team-based medical staff, quality improves. Innovation is possible. Rates of job satisfaction and patient experience improve (e.g., lower rates of error, better adverse event reporting, access metrics, health outcomes and use of guidelines).(4,5) Without it, the value propositions in healthcare will flounder at best, be dead at worst.

References

1. Spaulding A, Gamm L, Menser T. Physician engagement: strategic considerations among leaders at a major health system. Hospital Topics. 2014;92(3):66-73.

2. Taitz J, Lee T, Sequist T. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012;21:722-728. DOI 10.1136/bmjqs-2011-000167.

3. Davies H, Powell A, Rushmer R. Healthcare professionals’ views on clinician engagement in quality improvement. The Health Foundation. April 2007. www.health.org.uk/publications/healthcare-professionals%E2%80%99-views-on-clinician-engagement-in-quality-improvement .

4. Perreira T, Perrier L, Prokopy M, Neves-Mera L, Persaud D. Physician engagement: a concept analysis. J Healthc Leadersh. 2019;11:101-113.

5. Spurgeon P, Clark J, Wathes R. Medical engagement and improving quality of care. Future Hosp J. 2015;2:199-202.

6. Spurgeon P, Mazelan P, Barwell F. Medical management: a crucial underpinning to organizational performance. Health Serv Manage Res. 2011;24:114-120. DOI: 10.1258/hsmr.2011011006.

7. Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2007. Available at www.ihi.org/resources/Pages/IHIWhitePapers/EngagingPhysiciansWhitePaper.aspx .

8. Studer Q, Hagins M, Cochrane B. The power of engagement: creating the culture that gets your staff aligned and invested. Healthc Manage Forum. Spring 2014. Spring 2014;27(1 Suppl):S79-97. DOI: 10.1016/j.hcmf.2014.01.008.

9. Scheepers R, Lases L, Oneybuchi A, Heineman M, Lombarts K. Job resources, physician work engagement, and patient care experience in an academic medical setting. Acad Med. 2017;92):1472-1479.

10. Akosa A. Physician engagement is critical to the success of any accountable care organization. J Manag Care Med. 2013;16(3):67-76. www.namcp.org/journals/jmcm/articles/16-3/Physician_engagement.pdf

11. Perreira T, Perrier L, Prokopy M. Hospital physician engagement: a scoping review. Med Care. 2018;56(12):969-975.

12. Spurgeon P, Barwell F, Mazelan P. Developing a medical engagement scale (MES). The International Journal of Clinical Leadership. 2008;16:213-223.

13. Spurgeon P, Long P, Clark J, Daly F. Do we need medical leadership or medical engagement? Leadersh Health Serv (Bradf Engl). 2015;28:173-184. DOI:10.1108/LHS-03-2014-0029.

14. Baker G, Denis J. Medical leadership in health care systems: from professional authority to organizational leadership. Public Money and Management. 2011;31:355-362, DOI 10. 1080/09540962.2011.598349.

15. Denis J, Baker G, Black C, et al. Exploring the dynamics of physician engagement and leadership for health system improvement prospects for Canadian healthcare systems. Canadian Foundation for Healthcare Improvement. 2013. www.hhr-rhs.ca/index.php?option=com_mtree&task=viewlink&link_id=11971&Itemid=64&lang=en .

16. Sears N. Five strategies for physician engagement. Healthcare Financial Management. January 2011.

17. Lee TH, Cosgrove T. Engaging doctors in the health care revolution. Harvard Business Review. 2014;June:3-9.

18. Rosen P, Burrows J, Greenspan J. Physician engagement in the transformation of the pediatric patient experience. J Pediatr. 2016;169:4-5. DOI: 10.1016/j.jpeds.2015.11.023.

19. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008:27:1235-1245.

20. Berwick DM, Nolan TW. Physicians as leaders in improving health care. Ann Intern Med. 1998;128:289-292.

Tactics for Increasing Physician Engagement

Some of the tactics to use in engaging physicians include:

• Initiating timely processes for rounding for outcomes with targeted questions, such as:

  • Tell me what is working well.

  • Are there any individuals I should recognize for something done well?

  • Are there physicians I need to recognize?

  • Is there anything we can do better?

  • Do you have the tools and equipment you need to do your job.”

• Action planning, thank-you notes, post-visit feedback(8)

• Recognize the multiple roles of physicians as customer, partner, or employee.(2)

• Hardwire CQI activities and successes across the system and highlight the positive experience of physicians for their patients, and their staff, in change initiatives.(6)

• Transform to a culture that encourages people to do their best.(2) Standardize what is standardizable; make the right thing easy to pilot and to implement.(7)

• Respect physicians’ desire for autonomy by fostering peer support and engaging them in decision-making.(9)

• Encourage relationship building(1) and alignment on goals and measures,(8) and account for educational opportunities on CQI and leadership.(4,15)

• Create a coalition of physician leaders to drive quality improvement and safety(2,18) and encourage participation in multidisciplinary teams.(14) Develop physician champions and focus on laggards.(7) This can help physicians to get away from their narrow individualistic practice focus to contextual perspectives around system CQI and goals.(15)

• Establish a current Physician Compact and use dyads to nurture and grow “organized professionalism.”(13) Make physicians partners not customers.(7)

• Consider paying for time spent on quality and safety initiatives.(2,15)

• Ensure financial incentives are well aligned. In addition, those engagement strategies do not focus entirely on the financial rewards.(15)

• Do not die on the sword of unreliable or poor data.(2) “Generate light not heat with data” per the Institute for Healthcare Improvement.(7) Revise quality reports so that they are not comparisons but useful measures that can drive change and betterment (e.g., instead of central line-associated bloodstream infections [CLABSI] per 1000 line days, show # CLABSI per month or # days since last CLABSI).(7)

• Demonstrate and share feasible and realistic savings.(16)

• Use listening tours or town halls to help establish trust and communication before projects are rolled out.(1,15,16)

• Recognize that having a stable executive leadership team is essential(6) and be bold with Board support.(2)

• Recognize intent to work at improving engagement with medical staff.(6)

• Explore use of external consultants to guide training and coaches to shadow physicians, provide feedback, and monitor patient interactions.(18)

• Create ways to recognize and address physician burnout, physician satisfaction, and physician concerns.(18)

• Have a robust onboarding mechanism for new members. Make physician involvement visible.(7)