Health Systems

_{Ten Evidence-Based Practices for Successful Physician Retention
By Hannah King, MPH; Carrie Speckart, MA}

_{Retaining qualified, dedicated, and satisfied physicians is critical to the success of Kaiser Permanente. Losing physicians greatly impacts patient and physician satisfaction, as well as continuity of care. There are also large costs.¹ A recent Colorado Permanente Medical Group (CPMG) study showed that patients whose Primary Care Physician (PCP) had left the medical group had significantly more hospital admissions, emergency and specialty visits, and laboratory and x-ray tests. These patients also had dramatically reduced satisfaction scores and greater disenrollment rates.² Compounding these issues is the difficulty in recruiting the right replacements from shrinking pools of primary and specialty care physicians. These are just some of the factors that combine to make a compelling case for focusing our strategies on supporting and retaining Permanente physicians. Although we currently engage in many programs to encourage physicians to remain with the program, there is more that can be done. This article outlines critical retention elements cited in the literature and provides several examples from the medical groups.}

_{Using Effective Hiring Techniques}

_{CPMG has become "militant} about fit," says Simone Ince, MD, Regional Department Chief, Internal Medicine, and a speaker at the 2002 Permanente Executive Conference. The first step to a lasting physician relationship, according to Dr Ince, is hiring physicians who share the values of the CPMG, clearly spelled out in the CPMG Code of Conduct. By using a cross-functional team of physicians trained in behavioral interviewing, CPMG asks specific, standardized questions to determine if the physician will fit in with the high-quality, patient-focused culture and behavioral norms of the physicians already in the group. Years of organizational research backs up their hiring philosophy: "The best predictor of future behavior is past behavior."³ CPMG interviews focus on how each candidate has acted in previous situations, such as working on a high-performing team, disagreeing with a colleague, and going to extremes for a patient. Of course, says Dr Ince, it is also important to ask traditional questions regarding the candidate's qualifications and interests.

Also integrated into the CPMG recruitment methodology is honesty about what a new physician can realistically expect at Kaiser Permanente. Empirical evidence emphasizes the importance of not only stating the positives but also the challenges of the position and the organization. In the literature, this is called a "realistic job preview."⁴ Jack Cochran, MD, Medical Director, CPMG, says, "We want the physician candidates to leave the job interview scratching their heads and thinking, 'is this the right environment for me, does this fit my values, am I going to be successful here?'" If the candidate is not given a good idea of exactly what s/he will be doing, what type of control s/he has over the work environment, and what support is available, the physician may not get off to a good start with the organization and is more likely to leave.⁵

Gracious Welcome and Startup Resources

Literature suggests that the first few days and weeks of employment are when the new hire is most open to embracing the organization.⁵ It's the organization's best time to secure the loyalty of employees, and many successful organizations seize this opportunity to impress their new hires. At Mayo Clinic, they are very conscious of welcoming new physicians and building loyalty through the use of symbolic gestures that say "you are now one of us" such as nametags, nameplates, welcome dinners and gifts, and receptions for new families. New physicians and their families that quickly feel a part of the medical group community are not only more likely to stay but are more likely to be fully committed to the organization.⁶

_{In addition to the symbolic gestures, it is critical to provide the resources that physicians need to do their jobs.⁷ In a recent focus-group survey of new physicians of The Permanente Medical Group (TPMG) in Northern California, many new physicians complained that they did not have the "nuts and bolts" to effectively begin serving members. They lacked lab coats or parking passes in their first days or weeks on the job, they did not have adequate training on the computer systems, and some were uncertain about how to perform crucial procedures--like making a referral or ordering a laboratory test. One physician stated, "I had no office/desk, no computer, printer or e-mail. In the days following, when I asked about getting a printer, I was yelled at by a nurse for asking." Yet this same group of 90 physicians said they were eager to get up to speed with their jobs as quickly as possible and were eager to excel but couldn't without the essential tools and training they needed to do those jobs.}

_{One other gift that welcomes a physician to Kaiser Permanente is a slow start. For new physicians, having time to acclimate to their practice by being given a lighter load when they first start out is essential.^6,7 This tactic gives new physicians time to attend orientation and training sessions, and to learn about systems on the job. In addition, many new TPMG physicians felt that they needed extra time in their schedules for opportunities to network and socialize with colleagues within their specialty, both within their department and throughout TPMG. "It is really helpful to have a lighter load when you first start out. It allows you more time to go through the steps."⁶ These opportunities effectively acclimate new physicians not only to the workload but to the medical group community.}

_{Orientation, Enculturation and Mentoring}

_{In addition to having the nuts and bolts supplies and the most basic training, new PMG physicians need timely orientation to their department, facility, and region.⁷ New TPMG physicians surveyed wanted practical orientation with a tour of the facility and introductions to chiefs and/or key department contacts within weeks of being brought on.⁷ They also wanted practical, department-specific orientation. Ideally, the department orientation should occur before the physician starts or very shortly thereafter.^6,7 David Shearn, MD, Director of Physician Education and Development, TPMG, says, "We must treat our new physicians like we treat our new members and provide a great care experience for them."}

_{In addition, the literature shows that the best orientation programs go beyond basic introduction to a department and provide an opportunity to "enculturate" a person into an organization to foster a feeling of belonging and loyalty.⁶ Richard Pitts, DO, Assistant Area Medical Director, Southern California Permanente Medical Group (SCPMG) in Orange County, has developed an orientation program entitled "Finding Your Path to a Successful Permanente Partnership." All new physicians meet together every two weeks for nine months, beginning in September each year. During these biweekly breakfast meetings, they are introduced to SCPMG's leadership and managers from various departments. They learn about Kaiser Permanente's mission, vision, and social purpose, as well as the SCPMG behavioral norms and operating principles. The sessions address specific aspects of Permanente Medicine to help independent-minded physicians adjust to a collaborative work environment and successfully obtain partnership. Not only do these physicians gain a clear sense of Kaiser Permanente and SCPMG, they get a clear picture of what is required of them to become a Permanente partner while at the same time building organizational commitment and creating strong bonds with other KP physicians across specialties and facilities.}

_{Many new PMG physicians feel a strong need for mentoring--for an accessible clinician who can answer questions and foster feelings of belonging.⁷ Research has shown that the ideal mentor role is to provide acceptance, confirmation, coaching, counseling, friendship, and role-modeling to the new employee.⁸ Specifically, physician-mentors help new physicians to learn the often-complex KP systems, to network with other physicians, and to answer clinical and operational questions. In addition, the mentor can help welcome the new physician into the community.⁸ Because mentors serve multiple roles, they must have a clear program, with training, that outlines the role each facility is asking the mentor to serve, provides time and some funds for the mentor to get to know the mentee, and provides opportunities to provide guidance and support. Dr Ron Copeland states, "As the OPMG (Ohio Permanente Medical Group) Medical Director, I cannot think of any better investment of our professional time, excluding direct patient care, than mentoring fellow colleagues."}

_{The Role of Leadership: Setting Expectations, Giving Feedback, Providing Recognition, and Listening}

_{The way a department or physician chief welcomes a new physician and demonstrates leadership plays a key role in a new physician's decision to stay with KP. Physician leaders who not only communicate organizational and individual goals and expectations, but embody them are more likely to retain the committed physicians working with them.⁹ Key leadership behaviors involved in the clear communication of goals and expectations include listening to new physicians and providing them guidance, feedback, opportunities, rewards, and recognition. These behaviors have been shown to increase commitment in our physicians and to make them feel a part of their new PMG. When physicians clearly understand how they are doing and what is expected of them, they are more focused, committed, and willing to stay.¹⁰}

_{Once physicians are hired and oriented, they need accurate, effective, timely feedback about how well they are or are not meeting expectations. The literature shows that effective performance feedback increases performance and satisfaction.¹¹ Physicians cannot improve if they don't know where they need to improve. Dr Cochran (CPMG) states, "We will have arrived as a culture when the courageous conversation is considered a thoughtful, humane gift and when we seek to receive and seek to give critical constructive feedback." In addition to feedback on performance problems, recognition must be provided for things done well.¹² This, unfortunately, is not done nearly often enough. In recent interviews with Kaiser Permanente physicians regarding the physician work environment, an overwhelming number of physicians stated that more recognition would be greatly appreciated.¹³ One physician stated, "I truly think that we don't necessarily need monetary recognition or gifts. All those things are nice, but I think it is far better if leadership just walks by you in the hall and says, 'You are really doing a good job and I appreciate what you have done.'" Empirical evidence backs this up and suggests that the most effective recognition is personalized, timely, and one on one.¹⁴}

_{It's not the money or perks but the relationship with one's leadership that can have the biggest impact in engagement and retention.¹² Yet communication is often missing because leadership perceives themselves as too busy to communicate or only communicates by e-mail and never in person. Physicians want to be listened to and to see that their suggestions for improvement are acted upon. If leadership listens and follows up on physicians' concerns these physicians feel significant influence and control over their work environment.¹³ Lack of perceived control was the most important predictor of burnout among a study of 1800 HMO physicians.¹⁵ Organizational leaders that listen and involve their physicians with designing service delivery are likely to have less burnout and more satisfied, happy, and committed physicians.¹⁶}

_Conclusion

_{The Care Experience Council (CEC)^a has been actively studying the Physician Work Environment for the past two years. In its analysis of the 2000 and 2001 People Pulse Surveys, the CEC found key drivers of physician satisfaction across five regions of Kaiser Permanente.¹³ These drivers correlated with "feeling supported to do what is necessary to satisfy members," and include influence and involvement over the work environment; strong leadership and effective communication; and being valued for diversity and recognized for good work. In the case of physician retention, if we can ensure that physicians have what they need to perform their jobs, are involved in decision making and improvement efforts, are listened to and receive feedback, and are recognized for their efforts, we will increase the likelihood of retaining Permanente physicians.}

_{Dr Shearn concludes, "Physician retention is more than keeping physicians from leaving the organization. It is about retaining the hearts and minds, commitment, and loyalty of our physicians." There are many opportunities for the Permanente Medical Groups to hire the right physicians (be militant about fit), orient and enculturate them, give them the tools they need to be good physicians including training and mentoring, and listen to them and recognize them so that they can provide the best possible care and service to members. In return for our efforts, we will create a community of highly satisfied and committed Permanente physicians.}

 

_{^a CEC is an interregional group whose charter is to investigate
and validate operational tactics and improvement practices related to member satisfaction with the care experience at Kaiser Permanente.}

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