Increasing communication gives primary-care providers a chance to express concerns, participate in decision making, and feel more invested in the organization.
Including clinicians in the hiring of peers allows for a better organizational “fit” and quicker integration into the practice.
Collaborating with providers on the design of performance evaluations and incentives gives a greater sense of control and satisfaction, even if it means scrapping the planned program.
Reducing clinical leadership’s patient care hours allows for quicker response to operational challenges and more communication with clinical staff.
Recognizing and thanking providers for delivering excellent care helps boost morale.
Working in a community health center (CHC) means caring for patients with low health literacy, few resources, and challenges to adhering to therapy—while having high productivity demands. Despite these constraints, health outcomes in CHCs are equivalent or better than those in private practice, based on a study of 18 health indicators by UCSF and Stanford researchers a few years ago. The challenges associated with CHCs can lead to a high turnover rate for providers. These stressors can also fuel burnout and erode the traits a physician needs to excel in primary care: compassion, great communication, and empathy.
The financial burden of burnout and high turnover on cash-strapped health centers can be significant. Direct and indirect costs for recruiting and replacing family physicians, general internists, and pediatricians ranged from $236,000 to $265,000 per provider in 1999 dollars—and would be much higher today. Moreover, primary-care provider turnover can lead to a vicious cycle of increased burnout as more demands are placed on remaining PCPs in a clinical practice setting like ours.
The University Muslim Medical Association (UMMA) Community Clinic is a medium-sized, federally qualified health center founded 20 years ago in South Los Angeles to bring high-quality primary care to an underserved community. The University Muslim Medical Association began as a part-time volunteer-staffed clinic. Today, it is a full-service medical home for nearly 7,000 residents, with 25,000 primary care and behavioral health visits each year.
In UMMA’s recent past, the annual turnover rate for providers was about 25 percent. This is on par with the current average for a representative sample of 25 clinics in Los Angeles, according to data being collected by the Los Angeles Practice Transformation Network. Half of our providers were temporary or locum primary-care clinicians. Our leadership was no different; There were four medical directors in the previous six years. Our patients noticed. As one astute patient commented, “I see a different doctor each time I come! I love the one I saw last time and I’m sure this one is just as good but how come they never stick around?”
The leadership team that joined UMMA during the winter of 2015-16 had a vision for how to turn the tide. It sought to create a sustainable culture that would invest in its workforce and infrastructure to reap the rewards of higher quality health care and staff retention. The goal for our first year was to fill the open positions with providers who fit our clinic’s culture of respect and compassion and to cut the turnover rate in half.
UMMA leadership took several steps to improve primary-care provider satisfaction by enhancing communication, responding to workplace challenges, and rewarding excellence and teamwork.
Individual staff meetings: Leadership held one-on-one meetings with every staff member to learn why people were unhappy and what we could do. We listened to their perceptions of the clinic’s strengths and weaknesses. Many providers felt they were being left out of key decisions, and that initiatives were implemented in a top-down approach and announced “out of the blue.”
Ongoing communication: We set up more frequent formal and informal meetings with providers to share feedback and clinical workflow updates, and to maximize their sense of participation in the myriad initiatives our clinic is implementing. The aim of this open door policy is to listen to clinicians’ challenges in the workplace, accommodate schedule requests whenever possible, and strive to remove barriers to delivering excellent care. One example of a problem we solved together involved the clinical workstations in patient rooms. We used to have clunky “Computers on Wheels,” or COWs, which could literally stand between the patient and provider in the exam room. Working with our IT department, we trialed different wall-mounted systems for the computers that could be folded out of the way. We opted for the one most providers found comfortable to use.
Freeing up leadership time: We reduced clinical leaders’ direct patient care responsibilities to allow more time for handling operational issues and communicating with clinical staff. The cost incurred by this change has been more than offset by the retention of staff and reduction in locum hours.
Rewarding clinical quality: At the suggestion of our providers, we have tied bonuses, at least in part, to patient satisfaction and clinical quality measures. This grew out of their response to our rollout of a proposed productivity bonus plan. Our intention was to recognize clinicians who were seeing larger daily volumes by offering bonus incentives for their care team. We assumed they would welcome the plan, but all but one voted against it. The providers felt it would incentivize quantity over quality. We’re now improving our data analytics to better track patient satisfaction and clinical quality measures.
Hiring policies: UMMA opted to include providers more frequently in the hiring of peers by having interviewees shadow a provider or have lunch together. The existing provider’s input was elicited afterwards and incorporated into the hiring decision. This collaboration allows for a better organizational “fit” and quicker integration into the practice, because the new hire has already met a peer who vouched for her or him.
Staff recognition program: We had heard stories of clinical staff being scolded by previous managers to boost their visit numbers without resources to do so. Others were reprimanded in front of their peers. To shift toward a more supportive clinical culture, we established a staff recognition program. This includes peer-nominated “Bravo awards” for all staff who have demonstrated excellent teamwork, gone beyond their normal job duties, or shown outstanding compassion to a patient or colleague. Recipients are acknowledged during monthly staff meetings, with gift cards for those who achieve a certain number of “Bravos.” In addition, managers are encouraged to regularly recognize staff across departments with something as simple as a personal “thank you.”
The “C-suite”: Chief Executive Officer, Chief Medical Officer, Chief Medical Informatics Officer, Chief Development Officer, and Chief Financial Officer.
Between June 2016 and June 2017, UMMA has been fully staffed with primary-care providers, and we have retained all our primary care and behavioral health providers. In other words, we reversed the trend and achieved a fully staffed practice with 0 percent turnover for one year.
We know it will take continuous work to ensure we are balancing budgetary, regulatory, and humanistic targets. We are confident we are on the way.
Humanism and transparency are embedded in the culture of UMMA. We are committed to treating each staff member with dignity. We believe that it’s only by demonstrating our dedication to staff, and empowering them in the workplace, that we can truly deliver compassionate care to our patients and best serve our community.
The author would like to acknowledge Nwando Olayiwola, MD, MPH, and Sonali Saluja, MD, MPH.