When it comes to having a formal strategy for clinician engagement, Hunterdon Medical Center CMO Robert G. Coates, MD, MMM, CPE, FAAFP, FAAPL, is of two minds: On one hand, he believes clinicians should want to do the right thing without needing such written guidance. On the other, he sees the value in spelling out expectations.
“We probably should have a formal strategy in place for engagement,” he says, but adds he isn’t aware of an industry precedent or template he could present to administrators and say, ‘Let’s institute this.’” Also, putting in place a program to support the formal strategy would compete for “scarce resources, including time and money.”
Coates is not alone in this thinking. Only 39% of respondents to an NEJM Catalyst Insights Council survey on the topic claim their organization has a formal strategy for clinician engagement.
Coates is also reluctant to formalize the practice because he believes engagement can arise more organically from other organizational efforts, such as an initiative implemented by Hunterdon Healthcare’s new CEO Patrick Gavin. Gavin plans to take each specialty group out to dinner and to visit every primary care group once a year. During these visits, he will solicit feedback that a team accompanying him, which includes a clinical leader and a scribe, will funnel back to appropriate leaders.
“This is a big change that is going to pay dividends. We now have a mechanism to start taking action on feedback,” Coates says. Nearly 40% of survey respondents report fair or poor responsiveness by senior leadership to clinician feedback.
Coates, who agrees with the 36% of survey respondents who consider the CMO to be most accountable for clinician engagement, says a scribe recently sent him quality and safety concerns that arose in one meeting that he never would have heard about otherwise. He says medical staff meetings, which used to be once a month but changed to quarterly when the size grew from 100 to 400 participants, makes it “tough to keep up enthusiasm.” He’s tried email, which he finds not everyone reads, and surveys, which were last used 5 years ago and didn’t have consistent measurements, but nothing has proven to be effective.
“I’m not sure engagement surveys get at the core of what’s being measured. How do you know if a clinician is engaged or not? Is it their productivity? Their turnover rate? Their participation in activities such as grand rounds? I’ve really struggled with this,” says Lucy Xenophon, MD, MPH, Chief Transformation Officer at Mount Sinai St. Luke’s Hospital in New York City.
Mount Sinai St. Luke’s also doesn’t have a formal strategy for clinician engagement, but, like at Hunterdon, the hospital president meets with teams “on a routine cadence,” Xenophon says. “Our clinicians have a good rapport with the president,” so even if they don’t get a yes to their request, they feel they’ve been heard, and their ideas considered. Council members commented in written responses that two contributors to clinician disengagement are not being listened to and their voices not being valued.
Xenophon says the president takes feedback a step further, bringing teams to work sites to walk through issues. For instance, when clinicians shared concerns about the recovery space allotted to cardiac catheterizations, a team — including the president — visited, watched the process, and saw the problems firsthand. The same happened with flags from the emergency department about the turnaround times for radiology. “Even though we didn’t solve the issue right then, we gave the message ‘we hear you and we want to hear more,’” she says.
Engagement also can come from giving clinicians input into performance measurements. For example, if hospitalists are told the percentage of patients discharged before noon is too low, they should be able to partner on how to bring those numbers up. “If the number is 12%, you can’t make the immediate goal 50% — they’re not going to get there,” she says. Instead, she works with the hospitalists to disentangle anything that would be holding up the discharges and to set interim goals “that are celebrated as much as the final goal.” Approaching this any other way, in her opinion, is “an exercise in disengagement and demoralization.”
P. Stephen Novack, DO, MHCDS, addiction provider at Ohio-based Avita Health System, says demoralization happens quickly when clinician feedback isn’t heard. “Physicians have much more to offer health systems in the way of improvement beyond what can be operationalized or monetized,” he says.
He points to the addiction program he started after identifying alcohol and substance abuse as a problem within the communities the health system serves. “About 50% to 75% of patients are following the program and are having good results, but 25% or more are notoriously bad actors — criminals, repeat customers, and the like — who aren’t complying,” he says.
To drive that 25% down, he says, would take time and resources to innovate, feedback he provided senior leadership. “Senior leadership fails to see the value in having a high-paid [doctor] working on clinical effectiveness instead of billable services,” but not being able to move the needle on that population “is discouraging and demoralizing to people who have to work with those clients.”