Why physician involvement can inspire higher performing healthcare
The level of physician involvement is positively associated with better performing hospitals and improved financial management, write Peter Spurgeon and colleagues.
The concept of employee engagement has considerable currency within the private sector because it is associated with improved performance and output. While there is no formal definition of engagement, it involves encouraging the workforce to be the best it can be which, in turn, improves the organisation’s performance.
Engaged employees are characterised by a belief and pride in the organisation for which they work, a commitment to boost its outcomes, an understanding of the wider organisational context that extends beyond their own defined job descriptions, a respect for colleagues and a willingness both to go the extra mile and to keep abreast of developments in their area.
While this might appear to be similar to general dedication, engagement differs because it requires reciprocity and mutual respect between the organisation and its employees. The evidence from business and commerce suggests that engagement is mutually beneficial, with higher engagement levels being associated with improved performance, increased customer satisfaction, reduced absenteeism, staff turnover and burnout and improved levels of job satisfaction.
The limited amount of engagement research in healthcare suggests that enhanced engagement leads to clear benefits for patient outcomes and value for money.
American research has shown that the level of physician involvement is positively associated with better performing hospitals, and improved financial management. Similarly, hospitals which have a high level of physician engagement in strategic planning and decision making out-perform those where there are lower levels of engagement.
The evidence, while sparse, is nevertheless consistent: a workplace culture of engagement is positively associated with a range of improved patient health and financial outcomes. If these findings apply to the UK, the focus should be on how the NHS initiates, promotes and sustains employee engagement.
Levels of engagement across the UK public and private workforces are generally low. Whatever the reasons for this, the ever-present need to provide improved healthcare with limited resources means that alternative approaches to meeting performance and financial targets must be considered; consequently, the NHS is beginning to engage with engagement.
One attitude survey of over 10,000 NHS employees representing all professional and support groups in 14 organisations suggested that engagement is influenced by a wide range of individual variables, such as age, ethnicity, role, length of service and workplace experience. Overall, the best predictor for engagement was a sense of being valued and of being involved.
These findings offer clear lessons for the organisation. Managers must ensure that there are effective structures in place to support and acknowledge employees’ contributions and to ensure they have an audible voice in decision making.
However, these initiatives are the responsibility of managers. Engagement, by definition, must be two sided, and within the NHS, where there is frequent grass-roots reorganisation, it may be difficult to promote and sustain engagement among healthcare professionals, since patients still have to be treated, irrespective of the policy initiatives that are imposed.
There is evidence that managing the changes that are regularly required of the NHS may be better achieved through enhanced engagement. Similarly, optimising healthcare provision with reduced resources requires, in part, the full use of employees’ skills, which has also been shown to be associated with high levels of workforce engagement.
Consequently, achieving top-down directives, meeting targets and delivering high quality care are more likely if the NHS engages its workforce – in short, tapping into the skills and talents of the workforce via an engagement strategy. It may be that the low levels of workforce engagement in the NHS reflect a situation where the case for engagement has not been made clearly enough or forcefully enough. However, engagement research is clear on two issues: first, engagement cannot be developed without sound leadership; and second, in the health sector, a key professional group with which to create engagement appears to be the doctors.
The benefits of medical engagement
- Better patient mortality rates
- Fewer serious incidents
- Maintenance of high levels of service provision and patient care
- Sound financial status
- Achievement of targets
- Maintenance of core standards
This means that developing engagement is the dual responsibility of the managers and the doctors, between whom there is often a well-documented tension. The challenge, then, is for managers to actively encourage and maintain doctors’ engagement in influencing and delivering the wider goals of the organisation. And for this to happen, both sides must be convinced of the value of engagement, and in particular, the clear benefits that enhanced engagement may have for patient welfare.
Now, new evidence suggests a clear association between medical engagement and improved performance indicators in the NHS. Based on the definition of medical engagement as “the active and positive contribution of doctors within their normal working roles to maintaining and enhancing the performance of the organisation, which itself recognises this commitment in supporting and encouraging high quality care”, a reliable and valid measure, the Medical Engagement Scale, has been developed.
Using this to collect data from over 23,000 NHS staff, including 3,500 doctors, across 30 secondary care trusts (three from each strategic health authority), the researchers found that high levels of medical engagement were very significantly associated with improved patient mortality rates; a reduction in incidents leading to severe harm; the maintenance of service provision in all areas, as defined by NHS performance ratings; financial status; care-quality; and the achievement of targets across all areas.
A comparison of the 10 trusts demonstrating the highest levels of medical engagement with the 10 trusts showing the lowest levels of performance (defined by the Care Quality Commission’s ratings), showed clear and significant differences in overall quality, financial management, core standards, and meeting existing commitments and national priorities.
These results show a clear and consistent link between medical engagement and performance, confirming that if doctors become more involved in service change and innovation, then productivity and quality outcomes will improve.
Because these findings are based on correlations – albeit consistent and strong ones – no conclusions can be drawn about causality. However, it would be hard to see how radical change in service delivery could be implemented by disengaged, disaffected and uncooperative medical staff.
The perfect model
Clearly, understanding what distinguishes those trusts with the greatest levels of medical engagement poses the greatest challenge, but if it could be done then it would provide a model for other trusts. This research suggests those trusts with the highest levels of medical engagement (and also with the best performance outcomes), had a number of characteristics in common – continuity of leadership at the executive level and a clearly defined strategy for improving engagement with their medical staff.
However, early indications suggest there is no single recipe for improving engagement. Each trust needs to develop a set of processes that work for its own personnel, culture and context. For example, this might involve examining various aspects of the trust’s communication systems; focusing on how information is passed from the trust board to key staff; the parallel receipt of upward information and how this is managed; and understanding what undermines the sense of engagement in individuals are all likely to be productive.
Two messages emerge from this. Continuity of leadership allows relationships to be established between management and doctors, and engagement doesn’t just happen. Those organisations that develop it, work at it.
While those trusts that demonstrate high levels of engagement may have started off with a better staff group than those who do not, it would obviously be impractical to replace poor workforces wholesale. Therefore, some means of improving engagement levels with existing groups must be considered, perhaps by considering the points outlined in the box below.
Managers ignore the process of engaging with their medical staff at their peril. But it is also essential for doctors to ensure their own involvement in the delivery of policy initiatives, service restructuring and care delivery. Patient welfare must always be paramount, but engagement research suggests that when doctors share responsibility for necessary service improvements, it is more likely that effective care pathways can be successfully implemented and service provision improved. The organisation must offer the opportunities and environment that will allow engagement to flourish, while the doctors themselves must be motivated to engage. Engaging with engagement means everyone’s a winner.
Ways of engaging the doctors
Promote stable leadership
Select and appoint the most suitable doctors through an open meritocratic system, such as by using assessments and independent recruitment agents.
Trust and respect between managers and doctors can be fostered by promoting honest bi-directional communication, allowing for challenge to existing systems and accepting the need for change.
Create a culture of responsibility
Provide clear role responsibilities, accountability and empowerment structures for doctors and managers, by encouraging doctors to accept responsibility and accountability, while ensuring that the organisation allows doctors to take decisions, rather than requiring them to refer these for management approval.
Encourage open and effective communication
Ensure formal and informal systems are in place so that all levels of
staff can have a voice that will be heard and acknowledged as legitimate.
Clarify expectations and enable firm decision making by reminding staff that behaviour which is disruptive and unreasonable will not be accepted.
Offer support and development opportunities to doctors
Providing opportunities to medical staff encourages their awareness of the wider role they play and the behaviours required of them.
Look to the future
Encourage staff to participate in outside events and enable them to seek continuous professional improvement.
Find out more
- Engaging for success: enhancing performance through employee engagement
- Institute for Employment Studies
The authors would like to acknowledge the support of the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges in the conduct of this study.