A Model for Improved Provider Engagement

Physician engagement is the extent to which physicians are willing to go above and beyond for the organization, are loyal and committed, and ask what they can do for the organization as opposed to what the organization can do for them.(1) Not surprisingly, physician disengagement increases costs, decreases patient satisfaction, and reduces quality of care.(2,3)

Emerging literature focuses primarily on strategies for addressing burnout,(4,5) which does not overlap completely with disengagement.(6) Burnout is characterized by emotional exhaustion, indifference toward patients, and a lack of a feeling of personal accomplishment.(7) Fewer models covered in the literature address engagement,(8,9) leaving gaps for organizations attempting to address disengagement.

Similarly, most interventions focus on physician experience,(8,9) although allied health professionals (AHPs) such as nurse practitioners and physician assistants deliver an increasing proportion of care.(10-12) Few models incorporate both physician and AHP experience, which we define to be “provider” experience. We describe here our provider-organization model focusing on communication and relationship building to improve provider engagement.

Organizational Context and Key Components

Cambridge Health Alliance (CHA) is an integrated safety-net health system in Massachusetts, providing care to 140,000 patients at three hospitals and 15 ambulatory care practices. We employ about 800 providers, of whom roughly 50 percent are AHPs.

Between 2013 and 2015, the organization underwent a systemwide strategic planning process to set the organizational priorities through 2020. Making the organization “a great place to work” emerged as a key theme, prompting the initiation of biennial engagement surveys. The first survey (April 2016, response rate of 63.8 percent) revealed that providers were in the 6th percentile nationwide with regard to engagement.

Similar to the listen-act-develop model used by the Mayo Clinic,(9) our institution engaged in a process for addressing provider engagement that had four key components:

1. Creating a deeper understanding of the problem.

2. Developing a theory of change.

3. Creating a structure to enable ongoing dialogue between leaders and frontline providers.

4. Piloting interventions.

To deepen their understanding of the problem, senior leaders engaged in a “listening tour” during which they visited 30 departments and clinical sites. A frontline provider and the director of organizational development performed a thematic analysis, drawing on responses to an open-ended question on the engagement survey and the listening tour notes. This identified systems and staff improvement (e.g., increased training of staff) and communication as top opportunities.

We developed a theory of change and implemented iterative plan-do-study-act cycles. To develop our theory of change, we drew upon existing models of organizational development,(13) employee engagement,(14) and physician engagement,(2,8,9) complemented by our internal experience.

Our resulting theory of change (Figure 1) hypothesized that interventions targeted at improving communication and building relationships would increase the responsiveness of leaders and systems to provider needs and deepen relational trust between providers and leaders. This dynamic creates a cycle that increases communication, strengthens partnerships, and continuously improves systems, thus leading to improved provider engagement.

Figure 1. Our model of communication and relationship building. *PESC = Provider Engagement Steering Committee. Blue arrows represent communication pathways.

To drive communication and relationship building, we developed pilots to build relationships between individual providers and their colleagues, department chiefs, executives, and operational leaders.

Communication and Relationship Building

Guided by our theory of change, we provided multiple vehicles to improve communication and build relationships between providers and among providers and leaders (Figure 1).

Provider Engagement Steering Committee. The organization understood that providers and leaders needed to work collaboratively. To that end, we created the Provider Engagement Steering Committee (PESC) comprised of inter-professional frontline provider representatives appointed by departmental chairs, as well as representatives from human resources, the physician organization, and executive leadership. Similar to patient care improvement initiatives that bring staff together with patients and families, the committee aimed to bring a collaborative and partnership-oriented focus to the process of improving provider engagement.

The committee was charged with advising on the organizational approach to prioritizing cross-departmental issues. It was co-led by the chief medical officer and two provider leads (an MD and a PA). The members represented their departments and communicated the work of the PESC with their departments. To ensure alignment across the organization, the committee leaders provided regular updates to and received input from the chief executive officer, the Chiefs’ Council, Medical Executive Committee, and the senior vice presidents (SVPs).

Executive Leader Rounds. We first created executive leader rounds in which executive leaders attended provider meetings to elicit input on an ongoing basis. Leaders were scheduled for 20-30 minutes and began with brief remarks that included background information regarding the purpose of the visit. The agenda was informal and the visit was spent primarily in a two-way conversation with providers. Leaders were invited to provide a short summary of topics and list any pending issues to the providers within two weeks.

Virtual Office Hours. Understanding that many providers are unable to attend in-person meetings, we piloted virtual office hours, or video conferences, between providers and senior leaders on specific topics that were identified by the PESC. These meetings were cited by an industry leader, the Advisory Board, as a best practice.(15 )Topics and leader bios were provided before the meetings. While we initially held them during pre- and post-work hours (7:30-8 a.m. and 5:30-6 p.m.), we later switched them to lunchtime (12-12:30 p.m. or 12:30-1 p.m.) because of low attendance, after which attendance improved (from an average of 5 to an average of 15 participants).

Stay Interviews. Drawing on emerging literature(16) and the experience of leaders at our organization, we piloted stay interviews. These structured conversations between leaders and providers were designed to clarify issues that were important to individual providers and address them before providers decided to leave the organization. One departmental chief and a senior medical director volunteered to pilot the stay interviews. The departmental chief piloted the interviews with all 33 providers in his department; the senior medical director piloted the interviews with regional medical directors with the goal of training the medical directors.

Peer Coaching. Drawing on prior experience with peer coaching at our organization, providers in two primary care locations participated in a one-hour training during regularly scheduled clinic meetings. This training focused on non-directive coaching, a combination of reflective listening and humble inquiry, to support professional fulfillment. Because one goal was to create community, we paired providers with different colleagues each month.

Improving System Performance

We used two primary strategies to improve the system’s responsiveness to provider perspectives.

First, the PESC identified institutional provider engagement priorities. We invited executive team members to the PESC to discuss each priority, thus providing opportunities for leaders to gain an appreciation for providers’ perspectives to better inform operational changes. For example, concerns about provider safety prompted a discussion between the PESC, the chief quality officer, the chief of public safety, the senior director of risk management, and the patient safety clinical risk manager. This led to the invitation by a frontline provider to join a workgroup designed to address safety.

Second, our organization concurrently implemented a process improvement program using lean methodology. PESC leaders coordinated with the director of performance improvement to encourage providers to participate in performance improvement projects and align projects to institutional provider engagement priorities. Provider participation in performance improvement initiatives has been shown to improve engagement.(17)

AHP-Specific Engagement

The PESC included AHPs such as physician assistants, advanced practice registered nurses, licensed independent clinical social workers, psychologists, and clinical pharmacists. Recognizing that there may be opportunities to improve engagement among AHPs that are different from those among physicians, we formed an ad hoc committee that developed recommendations that were endorsed by the PESC. These recommendations stated that the organization should (1) support a culture where all providers are treated as professionals and (2) create conditions that support an enhanced AHP voice.

Although AHPs comprised roughly 50 percent of providers, their voice was marginalized in the governance structure. The hospital subsequently amended its Medical Executive Committee bylaws to include AHPs as voting members and increased educational opportunities for AHPs.

Results: Process Evaluation

Provider Engagement Steering Committee. One year into its existence, the PESC and Chiefs’ Council were asked to reflect on whether the PESC was meeting its goals. Both entities concurred that institutional culture change is difficult and that the PESC was meeting the goal of increasing bidirectional communication. However, both groups agreed that the work should be better integrated into the existing organizational structure.

In addition, SVPs were interviewed by an independent evaluator. They expressed differing perspectives on the impact of the PESC, though most recognized that the PESC was doing important work. They noted that the PESC provided an opportunity to engage with providers directly and recognized its value in promoting better understanding of frontline provider experiences.

Some also expressed that the PESC created new channels to do things that may have been possible through existing structures. Some expressed doubt that the activities had gotten to a place where the fundamental issues had changed; others felt like the atmosphere within the organization was fundamentally different.

Executive Leader Rounds. Of the 55 anonymous providers responding to a survey, more than two-thirds considered executive leader rounds to be worthwhile and relevant, and they believed that their input was heard and their work was better understood by leaders. Providers commented that this was a “great idea – providers should feel like they know administrators” and expressed “[I] appreciate the opportunity to communicate directly with leadership.”

SVPs who had participated in executive leader rounds enjoyed the activity and felt they were effective in increasing provider engagement. SVPs strongly emphasized the value of face-to-face communication with providers. As one SVP noted, “Most effective? Leader rounds. Any of the activities that we’re doing that gets us out front and visible in front of [providers]. This has helped the most.”

Virtual Office Hours. Overall, 104 providers attended eight virtual office hours lunchtime meetings (attendance range of 3-25). Among the 31 providers who completed anonymous evaluations, two-thirds reported that the meetings were worthwhile and relevant, that their input was heard, and that their work was better understood by leaders. At the same time, providers recommended having a brief agenda and providing opportunities to elicit questions ahead of time.

SVPs who had participated in virtual office hours believed the impact of this activity was limited for several reasons: attendance was low, providers were reluctant to ask questions, and they were not in-person, face-to-face contact. As one SVP noted, virtual office hours “don’t provide the opportunity to develop long-term relationship,” thus highlighting the importance of a central focus on relationships. However, a few participants described them as exposing gaps in communication and noted that they were gaining attendance and might in time create more value.

Stay Interviews. Among the 18 providers who completed evaluation forms, more than two-thirds reported feeling more valued, felt the meeting was worth their time, and said that the leader who conducted the interview better understood what kept them at the organization. Eighty-five percent recommended that other providers participate in stay interviews.

The two leaders who conducted the pilot stay interviews noted that stay interviews helped them understand and articulate why providers are engaged, provided them with important information for tracking progress over the next year, and motivated them as leaders. As one leader noted, “I’ve heard such amazing insights in my short interviews with these (providers).”

Peer Coaching. Eighteen providers were invited to meet one-on-one; nine participated, each meeting an average of 2.5 times. Providers completing anonymous surveys reported positive experiences: “I found it powerful ... It was really refreshing. I was forced to stop and think about myself, my goals.” More than 80 percent reported that peer coaching was worth their time and could improve their professional development and engagement. In qualitative feedback, five of seven reported the lack of protected time as a barrier to participation.

Outcomes Evaluation

Provider engagement rose from the 6th percentile in 2016 to the 22nd percentile in 2018. The engagement index rose from 4.64 to 4.81, a statistically significant change (Table 1). The five drivers targeted by our interventions improved by an average of 10.9 percent (range 6.5-15.3 percent), compared to the average improvement of 6.2 percent among drivers not targeted by the interventions (N = 29, range 0.7 to 15.1) (see Appendix). Voluntary turnover decreased from a pre-provider engagement initiative 12-month rolling quarterly median of 10 percent to a four-year low of 6 percent.

In 2018, the Advisory Board included five burnout symptoms based on the Maslach Burnout Inventory.(18) Providers were in the 99th percentile of burnout, indicating high levels of burnout compared to their peers. The improvement in engagement to the 22nd percentile concomitant with very high level of burnout levels in 2018 may reflect several possible phenomena.

First, burnout and engagement are known to be related but do not overlap completely(18); that is, factors aside from burnout drive engagement and vice versa. Second, burnout symptoms may have improved but remained high. Indeed, the proportion of people agreeing with a validated question in 2016 “I feel burned out by my work”(19) and the 2018 question “I feel burned out” decreased from 53.5 percent in 2016 to 42.6 percent in 2018. It is unclear whether changes in this measure reflect improvement in burnout or differences in the wording of the question.

Finally, our efforts to improve engagement may not yet have reached the point of changing the clinical work environment that drives burnout in many settings. As posited by our theory of change, these system-level changes will increase over time as communication and relationship building lead to alignment of priorities.

The degree to which changes in engagement were due to the initiatives outlined in this article is unclear. Appropriate to the context of addressing complex organizational change, this work allowed for emergent design. There was no pre-specified intervention and thus we did employ a research design allowing for causal inferences. Consequently, the possibility that some or all of the improvement was due to other factors cannot be excluded. For example, regression to the mean, or the observation that values at the extremes tend to move toward the middle without intervention, could have contributed to the improvement.

While the degree to which regression to the mean may have contributed is unclear, the fact that other indicators improved (such as turnover) suggests that regression to the mean did not account for the full improvement. For example, turnover decreased and remained low for 10 straight quarters, suggesting a lasting improvement. Similarly, drivers targeted by the interventions improved by 4 percentage points above other drivers, suggesting that improvements were driven by the interventions.

Next Steps and Operational Implications

We anticipate that the foundation of relationship building and communication strategies will lead to greater alignment of priorities between leaders and providers, and to concrete changes that result in workplace improvement (such as workflow redesign). Thus, the model will increasingly address the systems and staff improvements that underlie the high rates of burnout.

Our experience demonstrates that efforts an organization takes in partnership with providers to promote engagement can make a difference. Our approach, which emphasized the principles of collaboration and focused on increasing communication and relationship building, was associated with increased engagement and decreased turnover.

Our data also indicate much room for improvement. While we are grateful to note improvement, our providers continue to experience high levels of burnout and disengagement. We have considerable work ahead.

References

1. Advisory Board. Engagement Index Methodology and Validation: Overview of Research Background and Survey Testing; 2017.

2. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017; 92(1):129-46.

3. Burger J, Giger A. Want to Increase Hospital Revenues? Engage Your Physicians. Gallup, June 5, 2014. http://news.gallup.com/businessjournal/170786/increase-hospital-revenuesengage-physicians.aspx?utm_source=Want%20to%20Increase%20Hospital%20Revenues . Accessed September 6, 2018.

4. Panagioti M, Panagopoulou E, Bower P, et al. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis. JAMA Intern Med. 2017; 177(2):195-205.

5. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-analysis. Lancet. 2016; 388(10057):2272-81.

6. Advisory Board Medical Group Strategy Council. Combating Physician Burnout: Five Insights to Help Restore the Balance; 2016.

7. Maslach C, Jackson S, Leiter P. The Maslach Burnout Inventory Manual, 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.

8. Shanafelt T, Swensen S. Leadership and Physician Burnout: Using the Annual Review to Reduce Burnout and Promote engagement. Am J Med Qual. 2017;32(5):563-65.

9. Swensen S, Kabcenell A, Shanafelt T. Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience. J Healthc Manag. 2016;61(2):105-27.

10. Cunningham R. Tapping the Potential of the Health Care Workforce: Scope-of-Practice and Payment Policies for Advanced Practice Nurses and Physician Assistants. Washington, DC: National Health Policy Forum; 2010.

11. Morgan PA, Strand J, Ostbye T, Albanese MA. Missing in Action: Care by Physician Assistants and Nurse Practitioners in National Health Surveys. Health Serv Res. 2007;42(5):2022-37.

12. Park M, Cherry D, Decker SL. Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in Physician Offices. NCHS Data Brief. 2011;69:1-8.

13. Gittell JH. New Directions for Relational Coordination Theory. In: Cameron KS, Spreitzer G, eds. Oxford Handbook of Positive Organizational Scholarship. Oxford, UK: Oxford University Press; 2011.

14. LoyaltyWorks. Maslow’s Hierarchy of Needs and Employee Engagement Psychology. https://www.loyaltyworks.com/news-and-views/uncategorized/maslows-hierarchy-of-needs-and-employee-engagement/ . Accessed September 6, 2018.

15. Hurst T. Your Data-Driven Road Map for Physician Engagement: 15 Best Practices for Maximizing the Return on Your Engagement Efforts, The Advisory Board, Jan. 10, 2019.

16. Vignesh AP, Babu MS. Stay Interviews: A Missing Facet of Employee Retention Strategy. Paripex-Indian Journal of Research. 2012;3(1):121-25.

17. Hess DW, Reed VA, Turco MG, Parboosingh JT, Bernstein HH. Enhancing Provider Engagement in Practice Improvement: A Conceptual Framework. J Contin Educ Health Prof. Winter 2015;35(1):71-9.

18. Advisory Board. Provider Burnout Index Methodology and Validation: Overview of Research Background and Survey Testing; 2018.

19. West CP, Dyrbye LN, Satele DV, Sloan JA, TD S. Concurrent Validity of Single-item Measures of Emotional Exhaustion and Depersonalization in Burnout Assessment. J Gen Intern Med. 2012; 27(11):1445-52.

Appendix. Engagement Outcome by Drivers

Drivers Targeted by Intervention (Average increase of 10.9%)

• This organization is open and responsive to my input.

• I am kept informed of the organization’s strategic plans and direction.

• Administrative updates I receive from this organization are useful.

• Decision-making processes at CHA are transparent.

• The actions of this organization’s executive team reflect the goals and priorities of participating clinicians.

Drivers Not Targeted by Intervention (Average increase of 6.9%)

• This organization provides excellent clinical care to patients.

• This organization provides excellent service to patients.

• This organization is well prepared to meet the challenges of the next decade.

• This organization is pursuing an effective EMR/EHR strategy.

• I have the information I need to assess my productivity and care quality.

• I am interested in physician leadership opportunities at this organization.

• This organization supports the economic growth and success of my individual practice.

• Clinical leaders (department chair, specialty director, lead MD) serving my practice area effectively communicate difficult messages that my colleagues and I need to hear.

• I have good working relationships with clinicians in my principal practice area.

• I have good working relationships with clinicians in the organization outside of my principal practice area.

• Clinicians and support staff work collaboratively.

• Disruptive behavior is not tolerated at my organization.

• Over the past year I have not been asked by this organization to do anything that would compromise my values.

• I would recommend this organization to a friend or relative to receive care.

• This organization recognizes clinicians for excellent work.

• My compensation and benefits are competitive with what I could receive elsewhere for a comparable role.

• I receive the necessary assistance from clinical support staff to succeed in my practice.

• I receive the operational and business support services (IT, billing, coding, scheduling) to succeed in my practice.

• This organization provides me with the supplies and technologies I need to succeed in my practice.

• This organization supports my professional development.

• My practice/office manager(s) are effective in their role.

• This organization supports my desired work-life balance.

• This organization understands and respects individual differences (gender, race, age, religion, etc.).

• I have the right amount of autonomy in managing my individual practice.

• I am able to secure my preferred case times.

• Skilled anesthesiologists are readily available at this organization.

• Procedure suites and operating rooms are run in an efficient manner.

• My orders are fulfilled in a timely manner.