Leadership Survey: Why Clinicians Are Not Engaged, and What Leaders Must Do About It

Insights Report · August 8, 2019

Analysis of the NEJM Catalyst Insights Council Survey on Clinician Engagement. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

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Advisor Analysis

By Stephen Swensen and Dave A. Chokshi

Clinician engagement is vital for improving clinical quality and patient satisfaction, as well as the job satisfaction of clinicians themselves. Yet nearly half of health care organizations (47%) are not very effective or not at all effective at clinician engagement, according to a recent survey of the NEJM Catalyst Insights Council.

A Slight Majority of Health Care Organizations Claim Effectiveness at Clinician Engagement

From the Leadership Insights Report: Why Clinicians Are Not Engaged, and What Leaders Must Do About It. Click To Enlarge.

The most effective means of engaging clinicians (physicians and nurses alike) is to involve them in organizational decision-making, according to 57% of respondents. Only half of survey takers consider their senior leadership’s attempts to involve clinicians in decision-making as “not very effective” or “ineffective,” however.

“The survey shows a clear pathway to engage clinicians — but [the industry] is not delivering on that,” says Dave A. Chokshi, MD, MSc, FACP, Chief Population Health Officer at NYC Health + Hospitals, the largest public health care system in the U.S. At a time when many clinicians are suffering from professional distress and organizational distrust, Chokshi says heightened engagement is essential.

The sentiment is shared by Stephen Swensen, MD, MMM, FACR, Professor Emeritus at the Mayo Clinic College of Medicine and Senior Fellow at the Institute for Healthcare Improvement, as well as Leadership Theme Leader for NEJM Catalyst. “Allowing clinicians to be disengaged with the organization is the opposite of the Triple Aim. You wind up with poor patient experience, higher costs, and worsening outcomes. This should be a serious focus area for health care leaders,” he says.

Health care organizations should have a well-communicated and well-understood formal strategy for clinician engagement, Swensen says. Unfortunately, only 39% of the survey respondents — who are clinicians, clinical leaders, and executives of U.S.-based organizations directly involved in care delivery — say their organizations have a formal strategy in place, with nearly two-thirds (62%) replying “no” or “don’t know.” Swensen adds, “For most respondents, if there is a formal strategy, it’s so terribly ineffective that people don’t know about it. Ideally, you’d like to see 100% of organizations with a strategy that 100% of clinicians know about.”

The Largest Share of Organizations Do Not Have a Formal Strategy for Clinician Engagement

From the Leadership Insights Report: Why Clinicians Are Not Engaged, and What Leaders Must Do About It. Click To Enlarge.

There is a discrepancy in the survey results between how executives perceive their efforts in clinician engagement and how clinicians perceive them. For instance, far more executives (55%) than clinicians (26%) indicate that their organization has a formal strategy for clinician engagement.

Respondents overwhelmingly rank higher clinical quality as the top way in which clinician engagement improves health care (selected by 72%). Swensen notes that Millennial respondents have a higher incidence than Baby Boomers of citing improved clinician satisfaction as one of their top two ways in which clinician engagement improves health care. “They’ve made the connection better than Baby Boomers that their own satisfaction is an important component of their engagement,” he says.

Just over a third of Insights Council members say that measuring clinician engagement is a management practice at their organization. Chokshi comments, “It’s difficult to drive accountability if there are no underlying measurements.”

Organizations also must make sure that “clinical leaders are actually at the table for big decisions,” Chokshi says. He points to NYC Health + Hospitals as an example. “Under our new CEO, it has become the norm that anyone in clinical administrative roles must maintain an active practice,” he says. The benefit to this is that leaders stay close to the front lines and can bring a realistic viewpoint to key decisions. For instance, his organization is adopting a new e-consult model between primary care and specialists. Clinical leaders are engaged in the process from the outset, offering not only the positive views, but also some of the challenges, along with patient impact stories from their own practices.

So how can organizations move toward greater clinician involvement in strategic decision-making? “Dyad and triad leadership models work well in promoting clinician engagement and have a huge advantage in communication and perception of involvement in strategic decision-making,” Swensen says.

Chokshi believes the onus is on administrators like himself “to take the first step toward better clinician engagement,” noting that clinicians are busy. “It’s our responsibility to set up structures and pathways for feedback and to present an optimistic way forward,” he says. Council members dinged senior leadership for lacking responsiveness to clinician feedback, with 39% calling their organization’s responsiveness fair or poor.

That sentiment is echoed in written comments to the survey, where respondents expressed concern over a lack of listening by leadership, a lack of respect, and a lack of a valued voice in key decisions. One clinical leader says the biggest contributors leading to disengaged clinicians are “inconsistent or contradictory leadership messages” and “lack of listening to frontline clinicians.”

Swensen says that righting this ship will likely be easier for organizations with a majority of clinicians employed (rather than contracted or affiliated). He also believes there is a difference between how engaged physicians feel compared to nurses and other clinicians, who tend to be further removed from leadership roles.

“The more layers between frontline clinicians and those making momentous decisions about how care should be organized, the more cynicism and disengagement you’re likely to experience,” Chokshi says. “Improving patient care should be the major motivation for organizations to change and change quickly.”


What are the biggest factors in fostering sustainable clinician engagement?

“Treat them with respect and work on communication as if what they do matters, rather than a commodity. I recently heard a Medical Director tell one of the physicians that he was nothing but a commodity. How horribly sad!”
— Clinician at a large nonprofit community hospital in the West

“Respecting time (weekends, holidays, meeting times). Choosing things that affect every clinician, not just the ones bringing in the highest revenue. Resources (e.g., social workers, nutritionists, psychologists) to help us help our patients in the ambulatory practice, not just inpatient. Truly including clinicians in the field, not just administration, in decision-making.”
— Program director at a nonprofit provider in the South

“Recognize importance of all clinical disciplines in decision making; Identify appropriate metrics for quality outcomes as counterbalance to financial outcomes.”
— Director at a small nonprofit community hospital in the Midwest

“Culture, a sense of us-ness. Group practice mentality.”
— Director of service line at a for-profit community hospital in the Northeast


What are the biggest contributors leading to disengaged clinicians?

“EHR inefficiencies, regulatory compliance burdens, time-based work restrictions causing a mad dash to finish tasks regardless of patient needs, bureaucratic barriers to providing care, reimbursement denials that generate more clerical burden, focus on revenue over patient and provider satisfaction.”
— Clinician at a small nonprofit teaching hospital in the Northeast

“Feeling of insignificance. No feedback. No recognition for good work.”
— Clinician at a midsized for-profit clinic in the Midwest

“Burnout, administrative burden, loss of autonomy, and failure of leadership at the highest level to promote a culture of caring, respect, and inclusiveness.”
— Vice President at a small nonprofit community hospital in the Northeast

“Inviting them to the table and then not listening or offering them the opportunity to contribute.”
— Director at a large nonprofit teaching hospital in the South

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about clinician engagement. Respondents were asked about ways clinician engagement improves health care, the existence of a formal strategy for clinician engagement, the most effective initiatives at engaging clinicians, the effectiveness of clinician engagement at their organization, measurement of clinician engagement as management practice, accountability for clinician engagement, the responsiveness of senior leadership to clinician feedback, and the effectiveness of senior leadership involving clinicians in strategic decision-making. Completed surveys from 706 respondents are included in the analysis.

Clinician Engagement Improves Care Quality Most of All

From the Leadership Insights Report: Why Clinicians Are Not Engaged, and What Leaders Must Do About It. Click To Enlarge.

Insights Council members say clinical quality is the top outcome of having engaged clinicians. In a written comment, one clinician advises organizations to “choose performance and quality indicators that are proven to be directly associated with improved patient outcomes, including patient satisfaction.” This aligns with the first- and second-ranked choices of the ways clinician engagement improves health care.

Sixty-two percent of respondents say their organizations do not have a formal strategy for clinician engagement or they do not know about it. One executive says, “I feel like a lot of efforts are decentralized and not coordinated well.” A significantly higher incidence of executives (55%) than clinical leaders (42%) and clinicians (26%) indicate their organization has a formal strategy for clinician engagement.

Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.

Download Full Report

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