It has become evident stress looms largely as a factor in more and more referrals to North Carolina Physicians Health Program. Although certain stresses can enhance growth, others can lead to dysfunction. The higher the mental workload (the weight of decision making and responsibility, combined with the quantity of work) and the lower the decision latitude (the degree of control or influence one has in the workplace or amount of work undertaken), the greater the level of resulting stress.
In the following article, you will read about steps taken by Cape Fear Valley Health System in Fayetteville, as they have initiated a program to improve physician satisfaction and reduce stressors in the hospital setting when possible.

In the hospital setting, the Triangle of Service Excellence comprises three vital points: Patient Satisfaction, Employee Satisfaction and Physician Satisfaction. This article will focus on the concept of Physician Satisfaction, or perhaps more appropriately, Physician Loyalty, as this is probably the most difficult point to achieve and maintain in the current health care environment.

As physicians, we are constantly aware of the rising cost of practice in the face of declining reimbursement and increased regulation. The current professional liability crisis only adds to our general dissatisfaction with the practice of medicine. In their recent publication, Recovering Physician Loyalty: Lessons on Crafting a True Hospital-Physician Partnership, The Clinical Advisory Board pointed out that “…the changing economics of physician practice and hospital care are impacting the health of the physician-hospital relations”. They identified six phenomena impacting physician practice:

1. Physician price on the decline
2. Practice costs on the rise
3. Malpractice premium crisis
4. Resurgence of managed care
5. Cracks in the physician-patient relationship
6. Gathering specialist shortage

These forces are leaving physicians more dissatisfied; they are seeking opportunities to generate income through enhanced office-based and procedural productivity, over spending their time managing hospital patients. Hospitals are finding themselves losing sought-after outpatient procedures to freestanding centers and physicians’ offices.

The Clinical Advisory Board also identified eight “Key Drivers” for recovering and maintaining physician loyalty:

1. Quality
2. Efficiency
3. Technology investment
4. Clinical reform
5. Clinical practice
6. Revenue generation for physicians
7. Patient service

We sought to identify opportunities to improve our physician satisfaction, first by measuring this with a benchmarked survey provided by Professional Research Consultants (PRC) of Omaha, Nebraska. The results of this survey identified several key drivers unique to our medical staff and health system. We then employed professional consultants/facilitators to conduct focus groups with members of the medical staff to further define the key drivers, as well as opportunities to improve our rating. A Physician Satisfaction Task Force was established, composed of key administrative staff including the CEO, COO, and CMO, and physicians from the medical staff. This task force is responsible for taking the information from the survey and focus groups, and developing action plans that address areas where the greatest opportunities for improvement were identified. The task force has the ongoing responsibility of monitoring the progress with periodic feedback from mini surveys performed quarterly on a sample of the medical staff.

Through this process, we found several areas of concordance with the Clinical Advisory Board’s report. Our top four key drivers are:

• Administration
• Emergency Department
• Radiology Services
• Nursing Care

These key drivers are not necessarily problem areas; however, it has been shown that improvement in scores in these areas has the greatest overall impact on Physician Satisfaction and Loyalty. For each key driver, there is a subset of key drivers that greatly impact their respective scores. For example, for Administration, “Responsiveness to the Concerns and Complaints of Physicians” was the key driver, while for the Emergency Department, “Appropriateness and Efficiency of Work-ups by the ED Physicians” was the key. The timeliness of reports appearing on the charts was the key for Radiology Services, and for Nursing Care, “Nurses’ Care and Treatment of Patients” was the key. By using the focus group’s process, the task force was able to develop action plans that have been implemented to address these key drivers with some success.

Some of these action plans evolved into Performance Improvement projects that have, in turn, identified opportunities for a more efficient operation. For example, the Radiology Department determined the multiple steps in the process of ordering a radiographic study to getting an interpretation on the chart, and the barriers to the timely completion of this process. We are now monitoring and showing greater than 95% of reports available on the charts within 24 hours.

Another project currently owned by our Performance Improvement Department is the Physician Response Line. This is a device for receiving and recording physician concerns and complaints, and forwarding them to the appropriate manager for resolution. The concern is catalogued in a database and reported to the CMO, along with the manager assigned to resolve the issue, along with the timeframe the manager and physician agree upon for its resolution. This mechanism allows the Performance Improvement Department to spot patterns arising from specific units that may reveal process or resourcing issues that can lead to system changes. This process seeks to actively solicit physician input in identifying improvement opportunities, and involvement in the decision-making process.

Since undertaking this process, we have physician involvement in all of our strategic planning task forces and in our service line structure. Physicians have been integrally involved in our facilities master plan process, as well as our nursing and staff recruitment and retention task forces. Physicians have also been included in our information system and technology planning and vendor selection with a strong emphasis on the clinical support tools needed to support the needs of the medical staff. There are physicians on the Information Systems and Technology (IST) Steering Committee that reviews and approves all major IST projects; a separate Physicians’ Advisory Board to the IST Steering Committee is comprised only of physicians.

Finally, our hospital is investing in the development of our medical staff leaders through a series of seminars provided by experts in the area of medical staff issues, addressing current issues and solutions proven successful elsewhere. It is through these exposures that our medical staff leaders -- current and future -- have the opportunity to learn techniques and acquire leadership skills they might not otherwise acquire through “on-the-job training”.

As you can see, the concept of Physician Satisfaction/Loyalty extends beyond merely identifying and solving problems. This concept seeks physician involvement in every aspect of the hospital’s strategic and operational goals, and an understanding that physicians’ and hospitals’ futures are inextricably linked. We are learning how to work more effectively with our medical staff and together face and overcome the challenges in health care in the years to come. As hospitals seek to achieve clinical and service excellence, they appreciate that a physician-administration partnership able to manage the enterprise to a higher standard is required.