ABSTRACT
Academic medicine provides ample opportunities and resources for medical innovation, but presents unique challenges for physician-scientists, support staff, and hospital administration. In an environment that prioritizes individual research-related productivity for professional advancement, how can management guide its workforce toward common organizational objectives? Here, we describe an approach that aligns individual goals to a high-level strategic plan continuously by combining annual goal setting, performance management, mentoring of early career faculty, leadership training, and professional coaching to achieve the three pillars of the academic mission: patient care, research and teaching.
Key words: mentorship, coaching, performance management, academic medicine, strategic vision, healthcare leadership, aligned missions
INTRODUCTION
Healthcare delivery is complicated and dynamic, even more so at academic medical centers. Innovation in medicine is critical to improving treatment options for patients, but it puts additional demands on the physician–scientists and staff who drive scientific discovery and clinical improvements. Managing clinicians, in particular, requires organizational initiatives that balance productivity with factors that improve job satisfaction and engagement, and minimize burnout. Physicians and nurses are particularly vulnerable to burnout, which can negatively impact the quality of direct patient care, and when this results in their leaving healthcare, understaffing can compound the problem.[1,2] Globally, high-quality healthcare depends on managing available resources, including human resources, to maximize impact and improve clinical outcomes.[3–5] At Dana-Farber Cancer Institute (Dana-Farber) we found that five related areas are key to successful workforce management: goal setting, performance management, mentoring of early career faculty, leadership training, and professional coaching.
Teamwork in the clinical setting requires a significant amount of planning to mobilize all the necessary staff to see to the patient’s needs during their visit, and to provide the proper support for their care and follow-up. Managing these teams requires directing individual efforts towards organizational objectives, and in hospitals such efforts ultimately optimize patient care and can reduce medical costs. At Dana-Farber, healthcare is delivered by multi-disciplinary clinical teams of medical oncologists, surgeons, radiation oncologists, nurse practitioners and physician assistants, radiologists, pathologists, and other medical specialists. Clinicians also rely on clinical and ancillary services that include clinical and genetic testing, infusion teams, patient navigators, resource specialists, specialized pharmacists, nutritional services, palliative care, psychosocial oncology, social work, and interpreter services. Coordinating all these different roles can be challenging in United States hospitals, but can be even more difficult in hospitals in countries like China, for example, where the volume of patients per physician is usually much higher, resources are limited, and there are geographic disparities.[2,6–8] Across all settings, workforce development in healthcare has the potential to improve system performance.
Teams of clinical providers and staff at various levels and with different skill sets allow physicians to practice according to their clinical expertise, with other tasks delegated to staff skilled in those areas. For example, this can free up physicians to evaluate all new or complex patients, while Nurse Practitioners and Physician Assistants follow up with returning or existing patients under the supervision of an on-site physician.
The training of nurses, and the clinical tasks for which they qualify, differs from country to country. This impacts how much they can help physicians, and ultimately the patients. In the United States, masters level nurses, such as physician assistants, can prescribe medications. This type of clinical training can free-up physicians and expand provider capacity for improved patient access, especially in rural areas with fewer providers and where it is more difficult to recruit physicians. At Dana-Farber, specialized registered nurses called oncology nurse navigators do many of the tasks that do not require advanced clinical training, such as answering straightforward patient phone calls.
Teamwork and performance management of all staff are important factors in ensuring that proper care comes together seamlessly, especially from the patient perspective. Moreover, teamwork that results in superior patient experience can provide a competitive advantage for attracting more patients.
ACADEMIC MEDICINE ENVIRONMENT
Academic medicine presents unique challenges, and the different aspects of the hospital’s mission can draw physician time and effort in different directions. At academic healthcare institutions, in addition to providing and delivering expert clinical care to large volumes of patients, important missions like research and mentoring the next generation of medical professionals is woven into the fabric of organizational culture, and ultimately institutional operations (Figure 1). Having a welcoming and supportive environment for medical students, residents, interns and fellows further highlights the need for leadership training and performance management of all hospital physicians and staff, starting with goals for the organization that cascade down as achievable objectives.
Figure 1. The three main pillars of academic medicine: clinical care, research and teaching/mentorship.
In the United States, in particular, there is an additional goal of providing an excellent patient experience, because patients in the United States have a choice as to where they can receive care. The hospital workforce delivering that experience is a complex, tightly woven network of clinical, non-clinical, research, and administrative employees. In clinical roles, doctors, nurses, pharmacists, allied health professional, and many others provide needed clinical services and expedited patient care. Other essential employees who create and maintain a welcoming environment include facilities management, cleaning, and housekeeping. To provide the best patient care, all these roles need to work together seamlessly, so that each patient receives the best intervention and most efficacious care while minimizing time in hospital. This usually also translates to a better patient experience within budgetary and financial constraints. All of this starts with long-term planning and the goal-setting process.
GOAL SETTING
According to best practices, the top hospital leaders at Dana-Farber develop a long-term, high-level vision and mission for the types of research and the quality of care we strive to deliver, and for the operational and financial imperatives needed to support that quality of research and care. Top administrative leaders refine the agreed upon mission and vision into a strategic plan, institute operating priorities, and annual institute-wide operating goals. At most academic hospitals, including Dana-Farber, senior physician and nurse leaders are part of this team, providing important clinical perspective. Additional leadership roles come from senior and executive vice presidents in research, finance, experimental therapeutics, and human resources.
The institute goals cascade into departmental goals, which are then translated into individual goals, so that everyone knows how their efforts contribute to organizational success (Figure 2). We encourage supervisors to use SMART methodology (Specific, Measurable, Achievable, Relevant, and Time-Bound) as a basis for goal setting. The hospital, departmental, and individual operating goals are reviewed and refined on an annual basis. This goal setting process is the primary mechanism to ensure alignment of effort in service of the mission and vision of the organization. Achieving ideal patient outcomes requires intentional implementation of each of these overlapping management-related initiatives. Excellent clinical care with better patient outcomes and high research productivity is best achieved when the workforce is, and feels, supported. Physician–scientists, in particular, are expected to be highly productive and innovative with their research, publishing in high-impact journals. If publishing in academic journals is a primary factor in deciding academic promotions, as is the case at many teaching hospitals, direct patient care can be viewed as a distraction from the research mission. Refocusing individual objectives in alignment with overall institutional goals is particularly important.
Figure 2. Goal setting stages: an overall high-level vision and mission are supported by strategic and operating priorities, which cascade down through various stages of goal setting from institute-wide goals to specific individual goals evaluated annually.
PERFORMANCE MANAGEMENT
There are general principles of performance management that apply to both physicians and non-physicians. The general progress of the annual performance management process is usually monitored by the organization’s human resources department. First, annual performance reviews should be completed for every physician and employee each year. In the United States, it is usually the division chief of each medical subspecialty who evaluates physicians within their division. In larger clinical divisions (25–30 physicians) an associate division chief may share the responsibility of annual performance reviews for newer or early-career physicians. Having mid-career physicians take on an associate leadership role has the added advantage of mentoring emerging leaders. Supervision of non-physician staff is structured with a similar ratio, with each manager typically supervising between five to fifteen people. Having any more than this to supervise, a manager is unlikely to dedicate sufficient time and effort toward the effective performance of each employee.
All performance reviews should start with a self-evaluation by the physician or staff employee. This provides each employee with an opportunity to reflect on their own work performance over the past year and think about what they can accomplish in their roles for the upcoming year. It should be an intentional exercise to list and discuss how their existing and emerging goals can translate to the hospital goals and long-term mission. In this form, the employee or physician lists specific goals for the upcoming year. The employee’s supervisor then reviews each self-evaluation document and adds comments to align performance expectations between the employee and their supervisor. It is at this stage that the supervisor can refine or make suggestions to the employee on specific examples of what they have accomplished in the past year and then set specific goals for what they expect to achieve in the upcoming year to ensure alignment with the institute’s strategic plan and annual goals. The chart below (Figure 3) lists the various questions that can be used on self-evaluations and how they may differ for physicians and non-physician staff. Additional questions for physicians regarding job satisfaction are important for evaluating factors that contribute to burnout, which has an outsized effect on physician turnover and the quality of patient care,[1,9,10] and core competencies for staff target areas that have been identified as critical to effective hospital operations. Both sets of questions focus thoughts and discussions toward alignment of personal and institutional priorities.
Figure 3. Performance review self-evaluation.
The most important aspect of this process is the follow-up conversation. We recommend that performance and goal alignment conversations occur more than once per year, ideally on a regular basis as needed during regularly scheduled one-on-one meetings and not exclusively during the annual performance review. This helps to minimize misunderstandings between the employee and supervisor, align expectations, and eliminate surprises during the formal performance review. It is important to document annual performance evaluations on paper or with an on-line, confidential tool so that the supervisor, division chief, staff member or physician can refer to them as needed.
MENTORING EARLY CAREER PHYSICIANS
The goal of early career mentoring is to move physicians away from being solely focused on their individual achievement and towards a deeper understanding of their contribution to the organizational mission, while setting a roadmap for how they can be most successful in their careers as they rise through the leadership levels. One effort to proactively support new and early career physicians and to minimize performance and research productivity issues, is providing a structured advisory committee for each physician below the academic rank of full professor. These committees consist of senior and mid-career physicians, who routinely meet with mentees, approximately four times per year, to make sure they are on the right track for optimal performance and academic promotion. This is particularly valuable for physician–scientists at academic institutions, where the promotion process can be nuanced rather than straightforward or explicit. Mentors can also assist early career physicians with assimilating to the organization’s culture and making connections. A best practice in academic medicine is to ensure new physicians have a ‘Mentoring Committee’ that is written into their offer letter for employment. This reassures new physicians that they will be practicing and/or doing research in an environment that values them and supports their success. While the mentoring team may seem onerous, it has the advantage of providing a broader support network, with a variety of viewpoints, experiences, and expertise to draw from.[11]
LEADERSHIP TRAINING
Physicians go through years of rigorous clinical training, often paired with research, but are rarely trained as good managers and supervisors. Physicians are more likely promoted because they are excellent clinicians or researchers, not for their motivational skills or people management expertise. Throughout medical school, residency, and fellowship, physicians are selected and rewarded for their individual contributions, such as research publications and talks, leading successful clinical trials, or providing excellent care to patients.
At some point, physicians may realize, or are told explicitly, that they can have a bigger impact on clinical outcomes by leading an initiative or building a team. Mid-career physicians who are viewed as having high leadership potential are often asked to be division chiefs or program leaders in a hospital or health system. However, they frequently struggle to reorient themselves to a new way of working and may lack some of the specific skills necessary to do so successfully. While the determinants of the earlier individual success are important and impactful, these skills are not sufficient to make them effective managers or supervisors. To be able to adequately assess an employee’s (physician or non-physician) performance, certain managerial and supervisory competencies are required.
An often overlooked and yet critical element of new leader success is training. It is vital that leaders move from a sole focus on their own efforts to an outward perspective on working effectively with and through others. Some people have natural leadership abilities, but others need additional support to transition successfully. Proper training communicates new expectations explicitly. The goal of leadership training is to help emerging leaders understand their role in guiding others’ efforts to effectively realize the organization’s goals. Essentially, they must learn how to steer the boat by making sure everyone is rowing in the right direction, and how to handle it when someone is off course.
Leadership training can be performed internally, typically led by the human resources department, or can be provided by external consulting firms or academic business schools. These programs focus on developing leadership skills, including clear and professional communication, decision-making, and strategic thinking that can also help with managing stress, building effective teams, and career planning. The training should be focused on the leadership areas that physicians are typically not exposed to, such as creating a compelling vision, engaging and motivating others, and dealing with difficult human interactions. While these training programs can provide a great baseline of expected leadership behavior, the challenge is to provide training that supersedes the theoretical and provides concepts that can be translated into effective behavioral changes when the training is over. Additional training as a new leader can help with that person’s success in the role, which ideally translates to success for the team.
PROFESSIONAL COACHING
Coaching is distinguished from leadership training in that it is individualized, and while it provides leadership training, it can also be used for skills building, decision-making, relationship-building, and problem-resolution. Coaching can be effective in two different scenarios. One is the proactive approach, providing coaching for a physician who is going into a challenging leadership position, to give him or her tools to be effective and avoid inadvertent mistakes. A second option is when there may be specific issues that arise from a well-regarded but struggling physician or leader, to provide an objective assessment of the issue and hopefully a quick and focused intervention.
Coaches work closely with physician and executive leaders to understand their professional strengths, developmental opportunities, and business challenges. Topics in coaching can include conflict resolution, engaging and motivating others, creating an effective team, emotional intelligence skills, clear and professional communication, managing stress, change management, and career planning. Additional topics can include executive presence and change management, specifically how to lead through times of change. Increased knowledge in these topics empowers individuals to thrive in their roles and contribute effectively to the advancement of healthcare practices. The issues that professional coaches work on with physicians can overlap with the topics of formal physician leadership training programs, but are tailored to the specific needs of the struggling leader. Identifying factors impacting performance early on can assist the organization to find proper resources to help the employee and turn things in a positive direction.
Coaching is typically time-limited, such as an hour every two weeks for 3–6 months, with a clear list of objectives that are unique to the individual at this point in their career. Often a “qualitative 360” (interviews with 6–12 people that the physician interacts with on a regular basis, such as superiors, peers and direct reports) gives the physician and coach a clearer understanding of the strengths and challenges that the physician/leader brings to the coaching, as well as the current and desired impact of their leadership style.
The best outcomes for physician coaching are achieved when the one being coached is ready to learn new skills, and the coach can focus on areas that are immediately relevant while also understanding the nuances and pressures of the academic setting. Physicians tend to respond more readily to coaching if it is tailored to their immediate challenges, and sometimes if the coach has an advanced degree. Physicians have academic credentials with some form of an MD, with or without a PhD or MPH. Therefore, coaching can be more effective if the coach has a PhD in psychology or is a psychiatrist with an MD. The latter may only be needed for acute professional interventions. Whether the coach is internal or external to the organization, executive coaching is a strictly confidential process, and one reason physicians may be more receptive to coaching by someone external to the organization. Some key metrics to help determine if coaching interventions are successful may include measuring internal promotions, retention, and if the physician or manager is being coached is a leader of a specific area or group, if the employee satisfaction scores of that area improve over time.
CONCLUSION
Being clear and transparent about where the organization is headed and how it intends to achieve its mission and vision is a critical first step in workforce management. Translating that so every department knows how it will contribute to the organization’s success and how it must work together with other departments is an essential component of bringing out the best in its people—the organization’s most important asset. Once the organization and department goals are clearly communicated, it is in the organization’s best interest as well as the physicians’ and staff members’ best interests for early careerists, emerging leaders, and those with more experience know what is expected of them and whether they are meeting the mark. Mentoring, leadership training, performance reviews, and, when needed, coaching are essential tools to avoid problematic situations and to ensure that everyone is rowing in the right direction toward the best patient care and experience. All areas mentioned above would benefit from additional quantitative and measurable outcomes-based research.
DECLARATIONS
Acknowledgments
The authors wish to thank Leslie Gaffney for discussion and assistance with preparation of figures.
Conflict of interest
The authors have no conflicts of interest to disclose.
Data sharing statement
No additional data is available.
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