Health Systems

Successful Practices in the Physician Work Environment: We Work Together
By Karen Tallman, PhD; Jill Steinbruegge, MD; Michelle Hatzis, PhD

Permanente physicians seek to provide patients with excellent clinical care and an excellent service experience during brief office visits. However, many patients have heightened expectations for service, and some have preformed beliefs about their diagnosis and treatment. There is great variability in how well departments, modules, and teams respond to this and other challenges to achieve high patient satisfaction while building a positive work environment. This research asks what practices distinguish "teams" (departments, modules, or teams) that both enjoy a positive work environment and excel at satisfying patient expectations.

Identification of Successful Practices

The Physician Work Environment Workgroup of the Interregional Care Experience Council conducted focus groups in three regions to identify successful practices in the physician work environment. The central focus was identification of practices that discriminate "highly rated" teams (those with high scores on patient visit satisfaction and physician satisfaction surveys) from "medium-rated" or "low-rated" teams (those with medium or low patient and physician satisfaction scores). Physician satisfaction was defined as the average team rating on five physician survey items previously shown to be correlated with satisfaction.¹ Members of the Physician Work Environment Workgroup are listed in Table 1.

The Work Environment

The Care Experience Council is dedicated to identifying actions leaders can take to improve service. The work is grounded in the KP Results model.² Similar models have been supported by research in service industries.^3,4 The KP Results model hypothesizes causal linkages between leadership actions, the work environment, patient satisfaction, and outcomes:

Leadership Work Patient Clinical & Actions Environment Satisfaction Business

Outcomes

This model implies that a positive physician work environment is essential for retaining and recruiting physicians, for patient satisfaction, and for promoting important outcomes. Kaiser Permanente (KP) research has identified evidence for a link between the work environment and patient satisfaction.⁵

Methods

Physicians and researchers from the Physician Work Environment Workgroup conducted 20 focus groups in Georgia, Hawaii, and Colorado. The teams were asked questions related to what makes them feel supported to satisfy patients and the role of their local physician-leader in that support them. In Georgia and Hawaii, the participants were physicians, local physician-leaders, associate providers, and staff in teams. In Colorado, physicians and local physician-leaders from departments participated.

Findings

Five categories of successful practices that distinguished between highly rated teams and medium- or low-rated teams emerged from a qualitative analysis of the transcripts. Physicians in the highly rated teams use these five successful practices (Table 2).

The highly rated teams use all five practice categories, whereas the medium and low-rated teams tended to use fewer practice categories or use them less consistently. Contrasting features of highly rated teams and medium- and low-rated teams are displayed in Table 3. Quotes from physician team members exemplified each category of successful practice (Table 4).

The following are descriptions of the five successful team practice catagories.

1. Connect principles and values of team and region to daily work
Highly rated teams use the guiding principles and values from the region and from the team to guide daily decision making, align goals, and motivate the team. The most effective principles and values are simple and easily applied to daily work (eg, "First in quality, first in service," "Treat patients and team like family"). At decision points, members of the team deduce what is required from the principles and own their decisions. An example of a concept that guides highly rated teams is the belief that service and quality are compatible, not mutually exclusive, goals.

2. Demonstrate leadership by example
Physicians in highly rated teams model expected behaviors. They demonstrate--rather than ask for--exemplary behavior. Physicians and physician-leaders set the tone and direction for the group. Physicians give everyone in the team a true voice in decisions and empower nurse-leaders to participate.

A proactive, positive attitude is present in these teams. The positive physician example reaches the team members, who then reflect the modeling in their interactions with patients. In turn, physicians are cheered by the good examples set by team members. Positive patient comments to the team complete the feedback cycle.

In highly rated teams, physicians make timely team alterations. They set expectations for performance and manage to meet them. The team addresses interpersonal challenges rather than permitting them to undermine the team's functioning. The physicians anticipate and plan for upcoming changes instead of reacting to them.

This research was designed to identify practices that discriminate between the highly rated teams and the medium- and low rated teams. However, one identified leadership practice benefited all teams in one region: having open communication with
the regional leadership team. The physicians appreciated this practice and were empowered both by board updates in the facilities and frequent, small group meetings with leadership. These meetings were especially valuable because the physicians felt free to ask direct questions about tough issues--the "elephants in the room."

3. Emphasize team development to create supportive interdependence
Interdependence is working in a group as though you could not work without each other. These teams think as a system and distribute the workload across the team. Pervasive use of the word "we" is the most definitive sign of a highly rated team. Functioning in an interdependent manner is associated with reduced stress, a more predictable workday, and freedom from the feeling of having to carry the burden alone. Team members "jump in to help others." They get up and walk around to determine who needs support. Everyone works together to provide an excellent experience for patients and have a more orderly workday than when they worked more autonomously. Team members jointly examine and deal with problems and improve processes together. In time, highly rated teams develop a positive team identity, consistent with the team's principles and values. They are aware of the value and uniqueness of their team. Successful team development is associated with an emphasis on at least five foundational elements, which appear in Table 5.

4. Set goals within the team's sphere of influence
Teams that aspire to change major policies and programs outside the team's sphere of influence are vulnerable to becoming demoralized. Highly rated teams do not spend their energy trying to change the system; instead, they start with small, realistic goals. They get involved with making improvements instead of assigning blame and looking outside the team for a better work environment. By aspiring to achievable goals, team members increase their odds for success and build influence and control over their work environment. Success breeds more success.

5. Provide recognition and timely, constructive feedback
Feeding back information to all work group members is observed in the highly rated teams. Simple, verbal recognition received from a patient or team member is the most valued recognition. The physicians want to know that their effort and time are noticed. Public recognition given at large events, while valued by some, is not as helpful as simple comments by leadership and colleagues. Financial rewards are not consistently motivating. When interpersonal discord disrupts the work, highly rated teams deal with the problem in a timely manner, even if a physician is the disruptive team member.

Conclusions

Teams with the highest levels of physician and patient satisfaction are distinguished by rich interdependence, in which all team members actively support each other on a daily basis. Conceptually, they are guided by principles and values and have realistic, attainable aspirations. The activities of these team members are focused on strengthening the team and setting a positive example for each other while caring for patients. In addition, regular recognition and constructive feedback is provided to sustain day-to-day team functioning. Medium-rated and low-rated teams addressed some practice categories but did not consistently address all categories.

The highly rated teams were not identical to each other. Each highly rated team found its own unique way to use the five categories of successful practice. These teams discovered multiple routes to success.

References:

1. Janisse T, Tallman K. Care Experience physician work environment update: physician key drivers [presentation]. Care Experience Council, Oakland, CA, Nov 2001.
2. Steinbruegge J, Francis L, Stevens S. Understanding the care experience [presentation]. Permanente Executive Conference, Scottsdale, AZ, Nov 2-3, 1999.
3. Rucci AJ, Kim SP, Quinn RT. The employee-customer-profit chain at Sears. Harvard Business Review 1998; Jan-Feb: 83-97.
4. Brooks SM, Guth T. When service means more: its impact on customer opinions across work environments [presentation]. Wiley JW, chair: Practitioner Forum: Relating employee and customer opinion: drilling into the business. Society for Industrial and Organizational Psychology, 14th Annual Conference, Atlanta, GA, April 29-May 2, 1999.
5. Kam SM, Brooks SM. Touching the customer by understanding employees: preliminary linkage research findings from four regions of Kaiser Permanente. Perm J 1998 Spring;2(2):47-54.

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