High Turnover Takes its Toll

We are entering a highly competitive and disruptive phase of the healthcare ecosystem.  Over the next 10 years this new phase will be characterized by a battle for the “front door” of healthcare services between traditional health systems and new entrants.  That battle will be waged over creating a new healthcare “experience” driven by seamless and frictionless technology, high-performing and highly engaged teams, and a radically changed payer environment.

In our last blog we promised to revisit several issues that came up at our annual symposium, issues we believe are fundamental to this new front door to healthcare: employer solutions, telemedicine, real estate development, and leadership/team development.

We’ll start this series with leadership and team development, something that ultimately boils down to “culture.”  Mention that word to those in your organization who are oriented around metrics, and you will likely see a frown.  Culture is a “soft” issue that gets wrapped inside “organizational development.”  And no matter how many times you attempt to argue that there are ways to plan, execute and measure a high-performance culture, CFOs in particular haven’t typically embraced funding it.

But that may be changing because a number of problem areas are starting to bubble to the ranks of health system executive suites:

-      High rates of physician burnout

-      High turnover rates

-      Increasing costs for recruitment, retention and training

-      Greater visibility of organizational weaknesses through social media.

-      Increased pressure from boards/shareholders

 

A recent article in Healthcare Executive Magazine pointed out that, depending the study, the prevalence of burnout is between 30 to 50 percent of physicians, advanced practice providers, nurses and other clinicians.  The 2018 Medscape National Physician Burnout and Depression Report listed rates of burnout for emergency medicine, internal medicine and family medicine physicians at between 45 and 48 percent.

This blog is intended to provide a roadmap covering three basic concepts:

1.   Why culture and team development is critical to low turnover (or high employee retention);

2.   Why low turnover contributes to strong financial performance;

3.   How to approach culture and team development in an organized, measurable way.

Why Culture Matters

It was Peter Drucker, the famed management consultant, educator, and author, who said, “Culture eats strategy for breakfast.”  My experience is that most people know that culture is important, but have no clue how to purposefully achieve a high-performance culture. 

What we do know is that in a high-performing culture, not only is there low turnover, but people want to come work for organizations with a strong, purposeful culture.

Many CEOs are strong at setting the strategy and vision, and even building the foundation for a strong culture.  But that needs to manifest throughout the organization in the form of other leaders who can carry on what the CEO has started.

Good Teachers Make Good Leaders

Where organizations typically fail is in building this second tier of leadership and consistently leveraging that leadership to produce a high-performance culture.  At Merchant Medicine, we evaluate leaders using the following logic:

1.   Good communicators make good teachers.

2.   Good teachers make good coaches.

3.   Good coaches make good leaders.

4.   Good leaders lead to high-performing cultures.

 

Ask any executive coach and they will tell you it is better to work for a good boss at a bad company than a bad boss at a good company.  The word “boss” in this case is the wrong word.  It should be “coach.”

Coaches seek to make people better.  It’s in their DNA.  And sometimes there is the risk that making people better makes people more attractive to other employers.  But that’s where culture becomes the magnet that keeps people where they are.  Research shows that a strong culture trumps more money and lofty titles.

On the other hand, more than any single negative consequence of a weak or ill-defined culture, high turnover is easily the most damaging.  In some businesses, high turnover can have less damaging effects.  But in a face-to-face, retail-centric, consumer-oriented business such as on-demand medicine, high-turnover directly impacts patient volume.  And as competition increases for owning that “front door” to healthcare services, ignoring culture and high-performing teams is no longer an option.

Let me list a few examples that illustrate the logic:

1.   In its most basic form, when a person leaves a job, the work of that person isn’t getting done.  For example, I fell off my mountain bike recently and was pretty sure I had fractured my wrist.  I went to the local urgent care center, but their radiology technician just quit the week before.  They hadn’t yet found a replacement, so they weren’t doing x-rays that day at that center.  They sent me to one of their other centers: different neighborhood, longer drive, not very convenient.

2.   Another example: I had a client with high provider turnover, based largely on burnout.  When providers quit, their busiest urgent care centers (which typically rely on provider double coverage) are forced to give up their second provider to avoid another center closing.  When that happens, patient wait times double at the busiest centers.  In both of the above examples, patient frustration likely translates into high rates of “left without being seen” and lost future customers.

3.   When an experienced, proven employee leaves, a new person must be hired.  But with every new recruit you run the risk – a fairly high risk – that the person you choose will be the wrong person.  It happens all the time.  The cost of recruiting and hiring a new person can be measured.  The cost of hiring the wrong person and starting all over again is more difficult to put a price on.  But we all know it’s a high price.

4.   And finally, when a trusted member of the team leaves, the entire team is affected.  Team dynamics are a complicated weave of interdependent relationships.  Break one string and the balance of the entire team is thrown off.  Again, this is one that is more difficult to measure. 

These might seem obvious.  But if that’s the case, why does it happen so often?

What’s lost in this discussion around culture, is the impact of high-performing teams on driving top-line financials.  Bottom-line financials, i.e. costs, are fairly straightforward in urgent care.  And we sometimes spend most of our time on costs because we have more direct control over those.  Patient volume (through marketing) and reimbursement (through contracting) are more difficult to impact.  But when we look at average patient volume per provider in the urgent care business nationwide, we believe there is a great deal of room for improvement, largely because of dysfunctional teams.

Said another way, finding a method for building high-performing teams in urgent care can be like striking oil.  Flexing with the ebbs and flows of an on-demand business means predictable costs, high patient satisfaction and a team who high-fives each other at the end of the day saying, “We did it!”

And when you have a service line that reaches this point of team chemistry, it becomes a magnet for other talented people who want to join that team.  That translates not only into strong financial contribution, it creates sustainable competitive advantage.

Culture, leadership and team development projects are scary enough.  When you are ready to take a more formal approach to improvement, the goals should be very clear.  When we launch these projects for clients we have two goals: achieve the highest productivity in terms of safe patient throughput with high satisfaction; and provide a place to work that is fulfilling and where team members trust, support and enjoy one another.  Said another way, we seek to create a high-performing team that can flex with the ebbs and flows of an on-demand business without panic.

Get Real

To some of you reading this, your reaction might be, “Sounds like a Disney movie.  Get real.”

But what became clear at our symposium is that this IS real.  In a case study presented by Charlie Ireland, D.O., medical director at Advocate Medical Group’s  Immediate Care Centers in the Chicago suburbs, he demonstrated that not only is high turnover and burnout one of the most common challenges of medical practices, but that a solution to these “soft” issues is more achievable than many believe.

He started by describing a phase of self-confrontation.

“I was worn out,” he said.  “I wanted to quit.  I remember saying to my wife, ‘I have to change.’  But I remember thinking I don't know how to change.  I felt somewhat alone. But I didn't have a choice. I'm thinking it will require me to open up, rely on other people. I realized I didn’t have all the answers.  And doctors don't like to admit they don't have all the answers.”

This self-confrontation led to an informal intervention where Dr. Ireland organized an off-site meeting for anyone on the team who had an interest in putting issues on the table.  It was voluntary and unpaid.

“I was worried nobody would attend,” he said.  “But virtually everyone on the team showed up.   We talked about where we were, the present state.  We talked about how we were struggling, the landscape of medicine and where it was going. We agreed to focus on one or two goals. Then we brainstormed in the afternoon and that’s when the magic happened.”

Dr. Ireland’s team articulated a situation characterized by 10 conditions:

1.       Long patient queues at closing time;

2.       High team anxiety and high team disengagement;

3.       Slow and cumbersome technology infrastructure both for the front desk and providers;

4.       Team members who were wrong for the jobs they were performing;

5.       Team members who displayed inappropriate behavior;

6.       High turnover of both providers and support staff

7.       Greater than desired variation in processes and care delivery;

8.       Lack of Common Purpose;

9.       More reactive than proactive in care delivery;

10.   Lack of knowing who was in the waiting area at all times and with what complaints.  

Several attendees at the symposium looked at this list and said, “That’s us!”  No surprise.  These are characteristics of many medical practices today, especially primary care practices.  Read the recent article in Fortune on the disastrous impact of electronic medical record installations and you can see why this problem is only getting worse.  Furthermore, these characteristics are amplified in an on-demand environment, where patient volume is unpredictable.

 “A lot of people think healthcare is different than other industries when it comes to culture and team development,” says Suzanne Malausky, executive direct for Merchant Medicine’s organizational development practice.  “But it is no different.  Other industries have high turnover, burnout, inappropriate behavior and bad hires.  But these interventions can be highly effective at engaging teams to work together around solving problems.  People start thinking out of the box and take ownership of solutions when you go through an experience like this.”

The first thing Dr. Ireland discovered during his first off-site meeting was that every person who attended started thinking differently.

“Doctors and nurses feel like they can't change things,” he says.  “That is an absolute reality, especially with large health systems. And I don’t see how you change that unless you give your front-line people permission to make changes.”

By giving front-line team members permission to make changes, even on the fly, Advocate Medical Group’s three Immediate Care Centers saw dramatic improvement on their key performance indicators, as shown in the table below.

Advocate Medical Group Immediate Care Centers 2004-2017

table_001.jpg

 Getting Started

How do you get all of this started?  That is perhaps the most difficult part of confronting culture, not just for the team itself, but for the organization’s senior leadership.  The fear is that if you mess with things like physician leadership you risk causing an avalanche that results in mass resignations.  Nobody wants to be the one to start the avalanche with an innocent, well-intentioned intervention.  But the truth is, if you already are showing signs of team stress and a toxic environment, you risk that avalanche already.  It is not likely to get better or go away. 

The immediate challenge will be in convincing senior management there is a problem.  And that argument must be backed by data. You are unlikely to get support unless you present a convincing argument that there is a problem, and you have a high chance of significant improvement by addressing that problem in an organized fashion.  So you need to answer the following questions:

1.   What does your organization consider acceptable versus high turnover, and using those benchmarks does your organization have a turnover problem?

2.   What are the implications of that high turnover?  Can you link the trend around high turnover to a trend around lower patient volume or higher “left without being seen” rates?

3.   Have you measured provider and support staff engagement or rates of burnout?  Can you link those trends to high turnover and higher recruitment costs?

Once you have done your homework on the above questions, the next set of questions become most critical:

1.   Is your senior leadership team, all the way up to the system CEO, willing to explore whether you have a culture problem?

2.   If through that exploration you conclude you do have a culture problem, is the senior team willing to admit it?  Are they willing to take action, such as exploring cause-and-effect issues with your clinical team, including your most prized physicians?

3.   What will be the scope of this exploration?  Just one of your ambulatory service lines?  Just one site of one ambulatory service line?

4.   Who will be involved in that exploration and what are you willing to invest in that exploration in terms of time and money?

 

These are difficult questions to confront.  Most leaders feel between a rock and a hard place.  On the one hand, it feels risky in this competitive hiring environment to start poking at sensitive issues with providers and support staff.  On the other hand, the on-demand world will most likely see competition unlike any other service line, where mediocrity will no longer be acceptable to consumers.  Choosing to confront a toxic culture and poor team performance is what it means to be a leader in an on-demand world. It is also an investment in long-term success.

The Intervention

The intervention itself is not rocket science.  But many organizations think team development equates to things like Outward Bound or other experiential activities.  

“These can be great for new teams who need to get to know one another,” says Malausky from Merchant Medicine.  “But they don’t typically work when there is a toxic culture or poor team performance.  And people often struggle with how to bring the lessons learned from crossing a rope bridge back to work with them.  The impact is positive but not sustaining.”

Why?  Because those “get out of the office” experiences are just that, out of the office. They don’t involve the day-to-day work, which is a major part of team chemistry and interaction.

“The team may well need to get away from the work environment,” says Malausky, “but the focus should still be on the work and the specific behaviors that can make it better for everyone involved.”

Once you decide to move forward with an exploration, there is a fairly straightforward process to the investigation: data acquisition, interviews, workflow charting, technology inventory, and ultimately a series of meetings involving all team members.  We provide a detailed scope of work that describes the process and data request, and helps you get your arms around the steps and timeline involved.

Examples of Outcomes

At the end of this process, the outcomes can be as varied as the individual personalities on the team.  Typically, we end up with a rank order of the top-10 issues that create friction and discord.  Below are a few examples of items that might show up on that list.

1.   End-of-day backlog -- One common problem we find in urgent care is the clinical team is going home later and later.  They get behind in the middle of the day and never recover.  For those working a 12-hour shift, that 13th hour can be the breaking point.

2.   Wrong person/wrong job -- You may discover that you have a few members of the team in the wrong job.  One of the most common problems is hiring someone whose natural behavioral style doesn’t fit the job they are in.  The result is someone who is constantly adapting their behavior, which can be exhausting for that individual.  The DISC assessment tool looks at an individual’s natural behavioral style. In urgent care, which has a very “retail” feel, those natural styles are critical to success where the pace needs to be fast and customer engagement needs to be perfect.  For example, some providers thrive in a fast-pace environment: the day goes by fast, they love seeing as many patients in a day as possible.  Others need to take their time and need lots of breaks, which would force them into an adaptive style, ultimately resulting in burnout. 

3.   Leadership on the floor – What makes the most sense?  Often the default is physician leadership just because we assume the physician has to be the leader.  But that can be a faulty assumption.  Physicians are seeing patients, which means they are behind closed doors most of the day.  They don’t see problems in day-to-day work.  A more logical choice is often a nurse leader, someone who has the confidence of all players, someone who is assertive but respectful, and someone who has visibility to what’s going on.

4.   Support tools – One thing we have found is high tech is not always the most effective.  Sometimes low-tech serves better when it comes to workflow and communication.

5.   Common purpose -- What is the overriding purpose of the team, the one thing that defines what they do for your customers?  We sometimes find that a team has a clear purpose, but hospital administration constantly undermines that purpose with decisions that lack insight into the realities of on-demand medicine.  For example, we sometimes find that a common purpose like, “great medicine fast,” gets undermined by the EPIC EMR system, which, if not configured properly, can be very cumbersome with the check-in process.

Front-Door Up for Grabs

You are going to hear more and more about the battle to own the front door of healthcare.  Will it be Google or Amazon? Optum or HCA?  Or will it be your organization?

As much as many think technology will play the biggest role, it would be a mistake to assume that is the long-term play.  Technology has a way of becoming ubiquitous.  Instead, consumer-oriented, retail-centric industries always seem to boil down to the customer experience.  And although that experience may be enhanced by technology, high-performing teams are usually at the center.

With social media becoming a huge influence in exposing both the good and the bad when it comes to customer experience, ignoring team dynamics and culture is risky policy.

It may be time to take an honest look at where you stand when it comes to culture.