Published in the April 2019 issue of Today’s Hospitalist
A FEW YEARS AGO, leaders at a Washington health system made this chance observation: While they had little problem retaining hospitalist advanced practice providers (APPs), they struggled at times with turnover among their hospitalist physicians. Could there be a link between how both types of providers were hired, oriented and socialized into their new jobs?
As Matthew Metsker, PA-C, MPAS, site medical director for CHI Franciscan’s St. Anthony Hospital hospitalist program in Gig Harbor, Wash., points out, the “high satisfaction and retention with the NPs and PAs” started with their first weeks on the job. They benefited from being slowly brought up to a full independent clinical workload over the course of four to six weeks.
“They knew we wanted them to be good before they were fast,” Mr. Metsker says, but “we did have problems with physician turnover.” While he notes that many factors may have contributed, poor initial experience could have been one of them. “We were not being super-intentional about their onboarding.”
“Money spent today will keep clinicians working better and longer.”
~ Sheryl L. Williams, MD
Baptist St. Anthony Hospital
In the wake of that realization, group leaders decided to apply some of the APPs’ onboarding strategies to new-physician hires. “Let’s make sure we get these people in right so they are here for the long haul,” he says. “Let’s make sure they feel comfortable before we ask them to be fast as well.”
While Mr. Metsker doesn’t claim that onboarding modifications have guaranteed retention, he does think that well-thought-out, extensive onboarding helps. And since the overhaul, the group has had no open positions in his generally hard-to-recruit-to, small community hospital 40 miles from Seattle that’s staffed with 16 physicians and four NPs/PAs. “We haven’t had someone leave in more than two years, and we aren’t using any locums or per diems,” he says. “We feel very fortunate.”
Even without hard evidence, a growing number of hospitalist leaders believe that onboarding for the long haul works.
“100%, I am convinced that onboarding has a significant impact on physician engagement,” says Hardik M. Vora, MD, MPH, medical director for hospital medicine at Riverside Regional Medical Center in Newport News, Va. Dr. Vora believes effective onboarding should be a top priority for hospitalist groups struggling with retention and recruitment, as well as for patient satisfaction.
“Patients notice,” he says, “when physicians are well-prepared.”
Led by Dr. Vora, the Society of Hospital Medicine’s practice management committee is currently developing an onboarding toolkit. Hospitalist programs will be able to customize and use that kit to make a business case when negotiating for resources to support onboarding efforts. (See “Onboarding: the business case.” )
“Folks leave when they do not see a clear path to growth beyond the regular seven-on/seven-off schedule.”
~ Amit Vashist, MD, MBA
At Riverside, Dr. Vora says that he has secured funding to give new hospitalist hires a four- to six-week “ramp-up” period to ease into their jobs. During that time, physicians have greatly reduced patient loads and work alongside senior colleagues who serve as supervisors and mentors.
Others say effective onboarding can be done with even fewer resources. At St. Anthony in Gig Harbor, for instance, the hospitalist group concentrates its onboarding efforts in the first week. New hires spend nearly half that week in meetings and training sessions, some with the health system and others with the hospital.
The rest of the week is devoted to one-on-one shadowing of a senior clinician. Everything done that week is guided by a checklist and binder of information the group created over the last several years, including a “favorites” list in the EHR of electronic shortcuts. During the next few weeks, new hires carry lighter patient loads so they have time and energy to continue learning and getting used to the group culture.
Gaining some traction
At many hospitals, onboarding of new hires is even less systematic. At Baptist St. Anthony Hospital in Amarillo, Texas, the hospitalist group can offer only a little ramp-up time, in part because group members receive minimal dedicated time for onboarding. That’s according to Sheryl L. Williams, MD, who used to be the group’s medical director and now serves as medical director of quality for the hospital. “My facility isn’t going to pay for a week for someone to be here without seeing patients.”
“Too many programs leave things up to chance and hope for the best.”
~ O’Neil J. Pyke, MD
But that may change. Hospitalists recently began discussing how to provide more extensive onboarding, and those talks are gaining some traction. “We are saying that the money spent today will keep clinicians working better and longer,” says Dr. Williams. She believes, for instance, that new hires need dedicated time to sit with the hospital’s coding experts, quality department and group leadership.
“Brand-new doctors out of residency have no clue,” she says. “And I need time to talk with them about corporate compliance and quality metrics. If we can spend some extra time at the beginning ‘teaching to the test’—letting them know what we will measure them on, what is important to the organization and how to survive in this brand new world of being a hospitalist—that will increase longevity.”
In July, the group expects three or four new hires, all straight out of residency. “We are trying to put together an onboarding package,” Dr. Williams says, one that shouldn’t cost the hospital much in terms of hours but will still orient those new hires more effectively.
In a perfect world, she explains, “onboarding would take a week, and new hires wouldn’t be responsible for seeing patients.” In the real world, however, a new hire may not have any patients for only a day or two, then see a reduced load in tandem with a senior hospitalist.
Moreover, onboarding should include checking in with new hires every few weeks and then at six months and a year. That’s something her group already tries to do, Dr. Williams says, “but I will be the first to say it doesn’t always happen. It sometimes gets lost because we get so busy.”
A year-long roll-out
Because follow-up can so easily fall through the cracks, onboarding advocates say that it’s essential to have a formal process. Even better is having “a multistep onboarding program, a gradual roll-out over the first year,” says Amit Vashist, MD, MBA, system chair of the hospitalist division for Ballad Health, a health system with 21 hospitals throughout Tennessee and Virginia. “The premise is that if people are left to themselves, burnout sets in quickly,” Dr. Vashist notes. “We want to catch them at the right time and provide them with avenues to broaden their horizon and skills, so they not only survive with us but thrive.”
“You need to feel that the organization is investing in you.”
~ Rupesh Prasad, MD
Aurora Sinai Medical Center
Planning the nuts and bolts of what he calls “long-term onboarding” is a work in progress. But that effort has system support. Moreover, the health system plans to extend that onboarding to all clinicians hired, beginning with the hospitalists some time this fall.
The group will continue its current onboarding program, giving new clinical hires a day or two of orientation followed by two to four weeks of shadowing experienced hospitalists. Then, after 60 or 90 days on the job, “we will work on communication, crucial conversations and how to enhance patient experience,” Dr. Vashist says, an onboarding phase that may last six months. At that point, another set of onboarding “modules” will focus on quality improvement, physicians’ individual long-term interests and serving on hospital committees. Over the course of that long-term onboarding process, new hires will also be cross-credentialed and oriented to work in multiple facilities.
“This will help with physician morale and confidence,” which in turn will help with retention, he points out. “Physician loneliness is something we worry about in our hospitalist team, especially in our remote outlying hospitals. How do you get them to feel connected?”
Then there’s this problem that Dr. Vashist hopes enhanced onboarding will address: “Folks leave when they do not see a clear path to growth beyond the regular seven-on/seven-off schedule. Giving them opportunities to expand and diversify their skills will create a win-win situation for both the provider and the employer.”
Attention to group culture
Like Dr. Vashist, hospitalist consultant O’Neil J. Pyke, MD, who is based in Mountain Top, Pa., thinks extended onboarding is the better way to go, spread out over months. In his experience, most groups currently do only the first phase—orientation—if they have any onboarding at all. And even that, Dr. Pyke says, tends to be done too quickly and haphazardly.
He recommends that new hires work off a checklist and take several weeks (with a reduced patient load) to get up to speed. Group members also need to ensure that “there is no ambiguity with regard to what they deem to be a good—or even great—hospitalist at their institution.”
“I am convinced that onboarding has a significant impact on physician engagement.”
~ Hardik M. Vora, MD, MPH
Riverside Regional Medical Center
Necessary skills include ones that doctors don’t master in training: documentation, billing and coding, customer service, and patient experience. Just as importantly, new hires need to be trained in protocols and principles specific to their hospital and group, from how to do transfers to expectations about collaboration.
“Hospitalists who join practices already know how to be a doctor, but they can go off the rails if they don’t know how to do things your way and why they need to do them,” Dr. Pyke explains. “Too many programs leave things up to chance and hope for the best.”
Beyond initial orientation, the next phase of onboarding— which should take several months—would focus on integrating newcomers into the group culture. He recommends assigning mentors to regularly check in and make sure new hospitalists are not only learning what they need to know, but adjusting well to the job and the community.
“You have to insist on physician engagement” in the early days, weeks and months, Dr. Pyke adds. Otherwise, “doctors can become lost and disgruntled very quickly” if all they do is grind through long, busy shifts.
The high cost of disengagement
If all this onboarding seems expensive, consider the alternative. Dr. Williams in Amarillo, for example, talks about the cost of physician disengagement in terms of dissatisfaction and burnout.
“If all you do is 12-hour shifts, you will burn out,” she notes. “But if you approach this work from the very beginning as not a job but a profession, then you know that professionals behave in certain ways: They engage in local professional organizations, leadership, committees and projects. That gives you something other than seeing 20 patients a day so you won’t feel like a cog in the wheel, but a valuable member of the organization.” It’s essential, Dr. Williams says, to stress that professionalism with new hires from the very beginning.
“Enculturation”—learning a group and local culture and how to fit in—needs to be a key part of long-term onboarding, says Rupesh Prasad, MD, hospitalist and quality and utilization officer at Aurora Sinai Medical Center in Milwaukee. This is particularly true when so many hospitalists come to new workplaces from dramatically different ethnic, racial, economic and geographic backgrounds.
Dr. Prasad leared that lesson in his first job when he moved to rural Wisconsin after living and training in big cities. “You can imagine what a culture shock it was,” he says. “When I first came, I didn’t know what to expect or how to communicate.” He was greatly helped, he fondly remembers, by his program director, who told him after a few months that if he wanted to fit in, he had to start talking “about the weather, no matter what, and how the Green Bay Packers are doing.”
What he takes away from that key advice is that enculturation doesn’t just naturally happen. Groups hiring outsiders have to be intentional about welcoming them and teaching them how to live and work in their community.
The same holds true, Dr. Prasad says, when introducing newcomers to the values and goals of a new hospital or health system. Assuming doctors are smart enough to just pick up the local culture doesn’t always work.
In his current system, Dr. Prasad says that onboarding includes days being oriented both to the health system and the specific site, a gradual transition to a full patient load, shadowing, mentorship, EHR training, and a several hours-long leadership training course that was added only recently. Social events also help welcome new hires, while his medical group has “regular meet-and-greet networking sessions,” he says. Those include twice yearly off-site dinners and monthly town hall-style leadership meetings that most hospital staff can (and often do) attend.
“That’s good because, as a new hire, you need to feel that the organization is investing in you,” says Dr. Prasad. “The organization doesn’t just look at you as someone to come in and work. Instead, it wants to teach you all sorts of skills that are very important, not just in work but in life.”
Deborah Gesensway is a freelance writer based in Toronto who covers U.S. health care.
Onboarding: the business case
HOSPITALIST DISSATISFACTION is expensive. Estimates on how much it costs to replace a hospitalist range between $300,000 and $500,000, taking into account recruitment expenses, interviews, signing bonuses, loan forgiveness, relocation allowances, credentialing and privileging, EHR, coding and documentation training, and paying staff to orient and onboard new physicians.
“With really good recruiting, orientation and onboarding, you are going to cut your locums’ costs down.”
~ Matthew Metsker, PA-C, MPAS?
CHI Franciscan’s St. Anthony Hospital
And that doesn’t include lost revenue or the cost of paying others—from locums to overtime—to cover vacancies. Hardik M. Vora, MD, MPH, hospitalist director at Riverside Regional Medical Center in Newport News, Va., says he used those kinds of figures to make the case to his hospital C-suite for resources to support onboarding. “It’s costly,” he points out, “but if it retains one provider, it pays for itself.”
Matthew Metsker, PA-C, MPAS, hospitalist site medical director at CHI Franciscan’s St. Anthony Hospital in Gig Harbor, Wash., says a winning argument for his group has been avoiding the high cost of hiring locums. “Locums cost up to 40% more than your regular provider,” he says. “With really good recruiting, orientation and onboarding, you are going to cut your locums’ costs down, and that’s a big push for us.”
You can also make the case that more extensive onboarding will help improve patient satisfaction scores and other quality measures. As Appalachia’s Ballad Health, for example, hospitalist system chair Amit Vashist, MD, MBA, points out: “The system sees the benefit in fighting a national epidemic called physician burnout, but also in improving patient experience.”
Adds Dr. Vora, “The ultimate message is onboarding is critically important for many different reasons.” Whether you have a rich program with great funding or not, “you still have to engage your providers in some sort of onboarding process, and you have to figure out how to do that. Just because your administration doesn’t give you money for onboarding doesn’t mean you shouldn’t do it.”