Leadership

A Multi-Strategy Approach to Rebuilding Workforce Engagement

Case Study · May 9, 2018

High-performing health care organizations know that world-class patient care, innovation, and general success rely on a foundation of highly engaged staff. When Moffitt Cancer Center realized that workforce engagement had slipped below the national average, it deployed a multifaceted strategy that dramatically boosted engagement and leadership accountability and, in the process, transformed workplace culture.

Key Takeaways

  1. Driving engagement is a team sport and has to be “owned” by everyone in leadership. Any improvement strategy is exponentially more impactful when championed by your CEO and actively supported by the entire leadership team.

  2. Worry less about engagement scores and focus more on what engagement should look like in your organization. Once your team members initiate process improvements and partner with you in solving problems, you are where you need to be.

The Challenge

The H. Lee Moffitt Cancer Center and Research Institute (Moffitt), located in Tampa, Florida, is one of the largest cancer centers in the nation in terms of outpatient volume. More importantly, it is one of 49 Comprehensive Cancer Centers in the nation and is the only National Cancer Institute–designated Cancer Center in the state of Florida.

Founded in 1986, the organization quickly became well known for its remarkable patient outcomes, high-quality patient care, excellence in nursing, and world-class research. It also was praised by national and local surveys as an employer of choice, receiving accolades as a “best place to work” in the region and state for jobs in academia, for working mothers, for IT professionals, and for diversity. Moreover, previous external survey scores (conducted by various consultants) typically indicated a very highly engaged workforce.

In 2012, however, we noticed that our health care industry ranking according to the National Health Care Averages (a widely used benchmark provided by the leading health care engagement survey vendor, Press Ganey) had plummeted to the bottom quartile (19th percentile) of national engagement trends. These true peer comparisons were critical benchmarks for us.

Rectifying this “outlier” metric probably would have been motivation enough for our metrics-driven organization to get to work swiftly. However, two additional factors came into play. First, the dramatic fall in rankings came at a time when most health care institutions were still struggling to recover from the 2008 financial crisis. Moffitt was no exception, and it needed engaged team members to help the organization turn the corner on recovery. Second, in 2012, the cancer center welcomed a new CEO, who viewed workforce engagement as a priority and as an important indicator of senior leadership performance and success. With these two factors serving as additional motivation, our 5-year effort began.

The Goal

The organization’s goal was not just to rebuild a highly engaged workforce, but to create an environment and a leadership culture that would sustain high levels of engagement in the face of ongoing change. Such engagement would be critical as we embarked on a new strategic plan that required agility and innovation to position us for future success in a volatile health care market.

The Execution

Creating an environment and culture that foster engagement is certainly no “one size fits all” endeavor. Instead, as an organization, we found that a combination of modified best practices and new techniques that we created on a trial-and-error basis worked best.

Accountability

Our first step was to elevate the engagement score to a metric that would have an actual impact on the performance evaluations and incentive plans for all members of leadership. Initially, we required managers to participate in specific activities (e.g., reviewing results with the team, developing and completing action plans based on survey feedback) to qualify for their incentives. We then required them to achieve specific results (e.g., reaching a certain level of engagement and/or percentage improvement).

Although we tied only a small percentage of the incentives to engagement, the increased focus on this issue was remarkable. Despite initial pushback, management accepted as a new normal that engagement would be a leadership responsibility, ensuring that it now had a firm place on our organization’s scorecard (next to metrics related to turnover, budget, patient satisfaction, and quality).

Frequency and Response Rates 

Prior to our concerted efforts to increase engagement, we measured engagement about every 18 to 24 months. Now that engagement had been elevated to the same importance as other crucial metrics, we started to administer the Press Ganey engagement survey and report the scores on an annual basis. As a result, the survey was no longer seen as an “event” but rather was viewed as a way of keeping a finger on the pulse of how team members were feeling, identifying trends, and staying in touch with the organization’s most important asset: its workforce.

Relying on engagement scores for the calculation of annual incentives required all areas of the organization to have enough data points on engagement, which also helped to overcome skepticism about the accuracy of the data. To that end, we focused intently on increasing participation rates across all divisions and all levels to ensure that the data would be truly representative.

Several techniques were used to increase participation, including (1) the institution of a survey ambassador program in which >100 frontline team members served as local survey champions to encourage participation and to address concerns and issues among their colleagues; (2) the introduction of robust online resources such as an FAQ page, a live participation thermometer, a listing of participation rates by department, and a “wall of fame” for departments achieving 100% participation; and (3) twice-weekly updates on response rates, broken down by senior leaders and published as a group to tap into natural competitiveness. As a result, we were able to increase the response rates from 57% (2012) to 81% (2014 through 2016) and ultimately to 84% (2017).

Alignment and Involvement        

Starting out, we were convinced that the key to improving engagement was to develop customized plans focused on the specific concerns within each manager’s area. However, our survey results did not back up that theory. Therefore, in 2014, we decided to change strategy by (1) adopting a single, organization-wide theme and (2) involving as many team members as possible in developing solutions to problems within that theme. The combination of these two strategies became a powerful force for change and innovation.

Organization-Wide Theme: Each year, following a quantitative and qualitative analysis of the overall survey results, the top 3 to 5 themes were presented to senior leadership and then were narrowed down to 1 annual theme. Since the institution of this strategy, the selected themes have included Stress and Work-Life Balance (2014), Communication (2015), Collaboration (2016), and Resilience (2017).

Joint Problem-Solving: Four to 6 “Open Forums” were then held on campus to allow all team members to meet with senior leadership for informal discussions focused of the year’s theme, which was further broken down into subtopics. Each senior leader “hosted” a discussion station on 1 specific topic and the team members rotated through the room to participate in ad hoc chats focused on joint problem-solving and finding solutions. These “Open Forums” changed the tone of the conversation, creating a more collaborative dialogue between team members and leadership that evolved into an ongoing conversation of joint problem-solving and process improvement. The productivity of these conversations was greatly enhanced by an organization-wide effort to formally train team members and faculty in techniques of process improvement and project management. Team members felt empowered to take charge and make improvements in their own areas, and leadership not only supported but also publicly praised these examples of engagement.

Transparency

One consistent and important factor throughout our journey has been transparency. Specifically, the organization has made it a priority to provide all team members with access to survey data (including industry norms as well as rankings by position [nurses, physicians, leadership, support staff, and so on]) for comparison. To that end, we have encouraged managers to share work unit–specific results with their team members directly by creating simple slideshow templates into which managers can easily incorporate their own data.

We also have made it a priority to highlight the connection between feedback and improvement. We learned early on that even though many leaders made enormous efforts to achieve improvements in areas that had been identified as problematic, their team members often did not notice the improvements. Moreover, even if they did notice, they often did not make the connection that their feedback had been the impetus for the improvements because the link was not called out explicitly. Therefore, in an effort to make the organization’s responsiveness more visible, we have made a conscious effort to draw more attention to the connection between survey feedback and changes by making use of internal communication channels such as town hall meetings, the CEO’s monthly update, “Did You Know” flyers, newsletters, and announcements.

The Team

The team included the entire organizational development team, the Chief Human Resources Officer, senior leaders at the Vice President and Executive Vice President levels, the Chief of Staff, and the CEO.

Metrics

Engagement was measured as an average of Press Ganey items that capture agreement with statements related to such items as general satisfaction with and pride in the employer and likelihood to recommend the organization as a place to work, to receive care, and to stay employed in the future. This average score was tracked over the course of our intervention strategy from 2012 through 2017.

As we had hoped, engagement increased dramatically, with the organization moving from the 19th to the 87th percentile in comparison with national health care organizations based on Press Ganey’s survey norms.

Engagement Scores for Moffitt Cancer Center Compared to Press Ganey Engagement Survey National Healthcare Benchmark

  Click To Enlarge.

We also have observed consistently and steadily increasing engagement in the trend lines for two key employee groups: nurses and physicians. In addition to increased engagement, we have experienced improved trust between leadership and team members and have observed a greater sense of communication and collaboration in the organization as indicated by a steady upward trend of specific item scores in the Press Ganey engagement survey.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
Women of Impact Checklist

Lead In: Women of Impact in Health Care on Advancing Equity in the Workplace

Raising the standards of equity and wellness in our workplaces so we effectively advance health for the populations we serve.

Historical and Projected Numbers of Physicians, Nurse Practitioners, and Physician Assistants.

Growing Ranks of Advanced Practice Clinicians — Implications for the Physician Workforce

The number of NPs and PAs is growing rapidly, while physician supply has slowed. This research projects the number of NPs, PAs, and physicians through 2030.

IBM solutions to physician burnout roundtable participants: Christina Maslach, Paul DeChant, Tait Shanafelt, Namita Seth Mohta, Karen Weiner, Edward Prewitt

NEJM Catalyst Roundtable Report: Seeking Solutions to Physician Burnout

An NEJM Catalyst roundtable sponsored by IBM Watson Health brought together four experts, all deeply engaged in reducing physician burnout from different perspectives, to share in a robust discussion.

Pottharst01_pullquote - value-based health care leadership personas

Personas of Leadership in Value-Based Care

The deliberate nurturing of specific types of leadership personas seems to be a critical factor in the success of value-based care organizations.

Few Truly High-Performing Health Care Organizations

Survey Snapshot: What the High Performers Have to Say

NEJM Catalyst Insights Council members from high-performing institutions share their perspectives on what’s working and what needs improvement.

Morris-Singer01 pullquote clinician burnout community-building

Combating Clinician Burnout with Community-Building

Improving morale and reducing turnover with peer-support meetings and shared group email lists for clinicians.

Time Is What Matters Measure Figure D - Time Saved Compared to FY17 Average

Measuring Patient Quality of Life: Time Is What Matters

How Anne Arundel Health System created a meaningful measure for patients and providers.

Little Consensus Over Definition of High-Performing Organizations in Health Care

Leadership Survey: High-Performing Organizations

Health care is rife with metrics and rating systems that purport to differentiate the good, bad, and mediocre. Every clinician and leader wants to be affiliated with a high-performing organization. But what constitutes high performance in health care?

Eisenstein01_pullquote burnout collective action SDOH

To Fight Burnout, Organize

The social determinants of health — and physicians’ sense of powerlessness in the face of them — seem crucially missing from the discussion of burnout.

Framework for Comprehensive Community Wellness

Public Health–Health System Coordination: Upending the Siloed Status Quo

A five-point plan unveils ways that leaders of health care and public health organizations can take action to enhance community wellness.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Leading Transformation

227 Articles

Safety-Net Providers Lead Disruptive Innovation

Improved targeting of resources must be a consideration if we want to ensure health care…

Leading Teams

150 Articles

Lead In: Women of Impact in…

Raising the standards of equity and wellness in our workplaces so we effectively advance health…

Physician Burnout

41 Articles

Esprit de Corps: Turning Vicious Cycle…

Esprit de corps is the single most important indicator in which health care organizations have…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now