Susan Quirk is a Managing Director with Three-Sixty Advisory Group and has more than 25-years of experience partnering across healthcare organizations to improve key metrics by overcoming a myriad of issues related to engagement, productivity, recruitment, retention, and patient experience from the C-suite to the front line.
In this practical podcast interview, Susan Quirk flags the most common mistakes that organizations make when onboarding (or not onboarding) physicians, the importance of fit of the physician in both company structure and strategy, the list of reasons why physicians leave organizations, and the importance of peer mentors. Her formula to minimize the involuntary turnover of physicians is important for all physician leaders to hear.
Welcome to SoundPractice. Let's try to think back to those pre-COVID days of early 2020. Physician retention has been an issue you have worked on for many years. Would it be fair to say that things have worsened as time has gone on?
I think, yes. People are starting to get a sense of why physicians leave their organizations. Many CEOs I've worked with have been shocked when involuntary turnover takes over. I actually had a CEO call me two summers ago and say, "I'm so excited. I've got 10 ED docs." I said, "That's fabulous. Now, how are we going to make sure we retain them?" The biggest issue in retention is that physicians are not properly onboarded. It is a step that we just like to blow by. 63% of physicians are employed right now and during COVID, more folks are running to the shelter of employment.
Walking that bridge to employment and cultural fit is paramount because it can be very expensive. Using 2.5X compensation to replace a physician, it is not just the monetary expense – there can also be brand damage. So, it is important to take into consideration all the factors of why physicians stay and why they leave.
One factor to consider in improving the process is making sure Human Resources (HR) is involved. Quite often HR is not included in the recruiting process; they are considered an afterthought. Without the HR buy-in, once physicians get on board, in many cases, the HR department doesn’t want to deal with them.
You’ve said that the employment relationship may be doomed from the beginning because onboarding wasn't done properly. Can you give me some examples?
I have worked with organizations that have condensed onboarding to one week. So essentially, it's hand them a computer, sign up for benefits, introduce them to their colleagues, and get them credentialed. That's it. No mentoring. No understanding of how this physician fits into the larger organization structure strategy. No alliance built with a peer mentor. With one of my former colleagues, Dr. Ken Cohen, we analyzed that appropriate onboarding was at least six months.
First, the physician needs to be ingrained in the culture; to understand where they fit within the business strategy. Whether it's in clinic, whether it's telemedicine, what point they are in the system across the care continuum. And what are the performance expectations? It is important to be very clear about expectations in the first three months, six months, and a year. Assignment of a peer mentor and an executive team sponsor is key.
Now this sounds like a lot of work but think about all the work that went in to bring a physician into your organization. The work is worth it because then you have a physician that practices wisely against the metrics of a payer contract. They feel part of the team.
Let’s also not forget the physicians’ family. One of the biggest reasons why physicians leave a new environment is that their family just does not like it. They don't like the city. They don't feel welcome. I think a lot of it is organization specific, but it is important that the team gets to know the doctor and the family. The organization needs to support the entire physician package.
Let's shift gears to burnout because we certainly hear a lot about physician burnout. I'm interested to know your opinion of burnout today versus five years ago.
Well, it is an interesting shift. As I prepared for this interview, I referred to an article from 2014, one put together by a highly regarded organization in Minnesota. The question then was this: “What are the major issues of clinician burnout and professional wellbeing?” Here was the list in 2014; excessive workload, unmanageable work schedules and inadequate staffing, administrative burden, workflow interruptions and distractions, inadequate technology usability, time pressure and encroachment on personal time, moral distress, second survivor syndrome, patient care factors, job resources, meaning and purpose in work, organizational culture, alignment of values and expectations.
Job control, flexibility of time and autonomy, rewards, professional relationships and social support, and work-life integration were important. So, let's fast forward to COVID-19. There have been some great surveys conducted. One done by Medscape. I reviewed the survey findings from this summer. It was about 7,500 doctors. So, during that time, one third of the physicians that responded had a 25% reduction in pay. A lot of that has to do with the lack of elective procedures, 28% had a 26%-50% drop in pay. Again, a lot of it was due to the elective procedures. But physicians are lonelier because of telemedicine and activities via Zoom. They can't touch their patients. There's more relationship stress at home given the fact that they're working in a very dangerous environment. I don't think we've conquered many of the factors five years ago, that I just listed, I think we've added to it.
And the other thing I would just mention, I don't think we're in physician burnout. I think we're now in physician dumpster fire. And it's something that we really need to think about. And I've had the pleasure of working through a lot of this because Rome wasn't built in a day and it's not going to be fixed in a day, but you need to be really steadfast and focused. Many organizations aren't focused.
Do you have any solutions for us?
Here’s what I suggest. Approaching physician burnout straight on does not work, but engaging physicians in something they really care about does work. That could be improving workflows, limiting distractions, having them take more control of their environment, getting some of the weight off their shoulders. They start to feel as if, "Hey, this feels pretty good. You know what, I think I can make it."
Then introduce the concept of personal wellbeing. You must begin with assessing the environment and promoting understanding from the stakeholders. By stakeholders I’m talking about both physicians and administration. Assessing the biggest challenges are key. Use a heat map or visual demonstration of what physicians are thinking, and which physicians are at risk for burnout. I would also look at that data against the backdrop of involuntary medical errors. When you look at these data points, you can figure out to start. We need to listen. We also know physicians are resilient. Physicians are very resilient. The rigor and the focus they get during their training is amazing.
Excellent. Susan, let’s discuss physician compensation plans in value-based world.
A good physician compensation program balances productivity, quality, resource use, and advancing care information and clinical practice improvements. But in the current climate we are still productivity based. Productivity based is really something that we need to get away from. And it's really been difficult for CEOs to do that because we've never really made the switch from fee-for-service to fee-for-value.
On fee-for-service, we have one foot still in that canoe and we have a canoe moving in a fee-for-value environment. However, how do we really decide one way or the other? I can tell you productivity does not help physician burnout. All it does is keep the physician on the hamster wheel. So basically, I've come up with an approach that for a base salary, there's a certain level of activity you must meet to be paid. However, we're not going to pay you an incentive for that. We're going to pay you an incentive based upon practice improvement, based upon quality, and based upon the patient experience.
Those are suggested goals, but your goals would be based on your strategic plan. It could be more effective use of Advanced Practice Providers (APPs.) It could be a cost control goal. But that is how we’re going to pay you the incentive. We want you to focus on more than the hamster wheel and an RVU. We want you to focus on high quality cost-effective medicine, and patients who are happy with their encounter. So, until we really make the leap into this type of incentive, and we're clear that we mean it, burnout is just going to continue, and the dollars connected to these other critical measures for value-based care and the quadrant blame are just going to limp along.
May we talk in a little bit more detail about the formula you’ve developed to adequately compensate and retain physicians?
Sure. The first thing that comes into play is the compensation that is specialty driven. Each specialty has a compensation range, and there are essentially several percentiles: the 25th, the 50th, the 75th, the 90th and the 100th percentile. We really can't go over the 100 in terms of total cash because we're a tax-exempt organization. But for certain specialties and particularly for primary care, I have organizations that want to pay at the 50th percentile. That is crazy. What that is saying is that you want an “average” physician. Nobody wants to be cared for by an average physician. So, the mix between base salary and incentives coming up to that total cash compensation level is really the ticket. Let's just say, you want to align total cash with the 75th percentile. You can align the base salary with the 50th percentile, but for an incentive, you need to make sure that at target, the 75th percentile is paid. Because that is really the benchmark of quality that you want to have in your organization.
I think this is a good formula. I would not have a heavy base and a low incentive. Incentives are a great communication tool to show, “This is what is important to us.” It's quality, safety, and patient experience, or it's process improvement, or it's leveraging the use of APPs, or keeping the door to doctor metric down. It's going to vary by specialty, but that's really the way to pay as we plan for the future.
Knowing what you know, how big of a role online reviews play in the part of success of a practice?
Well, I think they play a very large part. Consumerism is extremely important, and we are moving in that direction. Practices, if they use a review tool, should make sure it is a good one and that at least 50% of patients are responding to it/using it. And sometimes you have to work it a little bit. You have to figure out how to deliver it, whether it's on an App or it's online, or it's right before they leave or it's within three days. In the primary care world, they are very important. In certain specialties, it may not be a big deal because the encounter may have been inpatient, or it wasn’t a very long encounter. For primary care, however, they need patients to return and really involve the practice in their network of care.
We touched a little bit, about HR's involvement. I'm interested in your opinion of the rate of change in the HR arena, say in the last 10 years.
HR transformation in healthcare is still a little bit behind the curve. And organizations, which still have a transactional focus, really need to up their game. I'll tell you why. First, they need a seat the strategy table. They need to be that strategic partner for the C-suite. And those are the types of nuances that are extremely important if you want physicians to relate to you. Second, the HR department needs to be more adept in understanding specific physician needs.
HR departments need to prove their worth, but if they are understanding the physician needs, and if the physician feels he or she is being listened to – and treated in a timely manner, it is worth everyone’s time. But the communication must be in the mode that the physician prefers. It might be via an App. It might be Zoom. It might be a personal visit to the office, whatever. The interaction must be timely and attentive in nature. This is extremely important. To improve the value of the physician engagement, the HR department really must work with the physician.
And by the way, the HR department feels the same way. We need to kind of come to a meeting of the minds and a meeting of the expectations, but it's all driven by really the C-suite and making sure that the HR partner is strong. HR business partners across the continuum also need to be equally strong and equally toeing the line. I was talking to an organization last week where 50 clinics in the network not toeing the line for corporate. As a result, they had lots of practices and policies which were amended for one-offs and you can't do that.
I also think that having HR understand the business strategy, the patient base, and the pressures that your physicians have on a daily basis. This will demonstrate a certain type of special empathy, which physicians will really appreciate. Another hint is to have HR focus on recognition and not all about money.
Great advice. Thank you so much for your time. My guest has been Susan Quirk, consultant, and national expert. Thank you very much.
Susan Quirk is Managing Director at Three - Sixty Advisory Group