Internist Rebecca S. Lee, M.D., medical director of North Shore Physicians Group in Danvers, Massachusetts, has practiced primary care in her hometown for eight years. "I am kind of born and raised where I practice, which I really love and which is part of our culture," she says. This is not to say that every physician at North Shore Physician Group’s Danvers location also was born and raised in the area. "But it is more of a community feel," she says.
Creating organizational culture
Reaching that community feel in Lee’s practice didn’t happen overnight or even organically. It took effort. Lee helped open the new practice near her home and had a say in everyone hired, from physicians to front-end staff.
Across the country, in northern Arizona, internist Derek Feuquay, M.D., also has worked hard with his group, Flagstaff Medical Center Hospitalists, and Flagstaff Medical Center administration to create an excellent culture in the group practice and hospital.
According to Feuquay: "We have created an employed practice where people just don’t show up and work together; they are friends, colleagues and teammates." Feuquay and his wife both joined the group about six years ago, and he became the lead physician in 2011.
When successful teams are formed, it’s because the hiring parties were able to look beyond training, certifications and clinical skills and to something more ethereal: "fit." So how does a physician seeking a new opportunity evaluate their fit? And just why is the organization’s culture so important?
What is culture?
Of course, culture has dual meanings in health care today. Cultural competence is all about understanding the body of knowledge and beliefs or the backgrounds with which patients identify because patients’ values and customs can influence their belief systems regarding health.
The same holds true for culture within a health system, hospital or group practice. Many of the beliefs and values are intangible - or at least difficult to pinpoint and measure. Louis Caligiuri, director of physician contracting and recruiting for North Shore Medical Center in Boston, which is affiliated with North Shore Physicians Group and the larger Partners Healthcare Network to which both belong, says that communication is a big part of the North Shore culture. "The lines of communication are open, and we try to be a physician-led organization."
Much of that can’t be measured, but Lee points out that she receives notification whenever one of her patients is seen in a Partners facility. That’s something an incoming primary care physician might want to know.
Other examples of culture include the mission, vision and values of an organization. Some of these are formal and published, driving how everyone from the medical director to the billing staff conduct business.
"The culture of our organization is one that supports professionalism," says Jonathon K. Foley, M.D., FACS, president of Cape Girardeau Surgical Clinic in Missouri. Foley, a general surgeon, says that the group focuses on "getting the right people, the most efficient processes, and the best technology to support the work of the organization."
Not every practice or hospital has formalized their culture. Other times, the leadership believes they have a particular culture, but word may not have gotten to the rank and file physicians or staff. Those that are most successful at having and sticking with positive cultures have identified and are driven by core values.
For Cape Girardeau Surgical Clinic, getting to the point they now are at grew from intentional behavior and actions, says clinic administrator Sarah Holt, PhD, FACMPE. "Years ago, we discussed as a group the kind of practice we wanted to become." Included in the group’s culture is a focus on applying formalized governance in "a fair and systematic manner," says Holt, along with valuing individuals and the group as a whole. In addition, Holt says, "We hire the best people we can find."
Why does culture matter to job-seekers?
Although physicians seeking new opportunities have much to consider and weigh, many recognize the significance of cultural fit when evaluating an organization. According to Caligiuri, some of the physicians he interviews mention that the organization’s culture is an important factor. "Some are explicit about it," he says.
And although physicians often are prepared to evaluate compensation or benefit packages, they might not realize the effects an organization’s culture has on the bottom line or physician benefits. "Culture drives satisfaction or dissatisfaction with compensation, call, salary and benefits," says Holt. She adds that culture also contributes to satisfaction with one’s colleagues - an important factor in a specialty such as surgery, where respect and collaboration are key. If not present in the culture, "problems develop, fester and finally erupt," says Holt.
Foley agrees. "The work we do is too stressful to spend energy fighting the organization," he says, adding that the organization "needs to support the work of the physicians and staff so that we can accomplish meaningful work."
For those who vet, interview or hire new physicians, it’s crucial to make sure that the culture is a fit for both the new physician and for the organization. Caligiuri uses the hospitalist program in Partners as an example. There tends to be more turnover in hospitalist positions simply because some physicians work in the job for a few years and then move on to a fellowship or other position. If a new hire also is not a fit with the organization, then turnover increases more, which can add to costs for the organization and upset a carefully developed culture.
Feuquay says that when he first arrived in Flagstaff, rapid growth meant equally rapid hiring of hospitalists, and some of the hires were not good fits. Even though the group and hospital continue to expand, both have settled into a more steady and purposeful way of handling their growth and success.
"Nothing makes an employed hospitalist feel more comfortable than a stable organization that continues to support their group," says Feuquay.
Megan Nordvedt, manager of medical affairs and physician recruitment for Flagstaff Medical Center, says cultural fit is everything when physicians join a new organization. "If a physician feels the culture is familiar and comfortable, warm, welcoming and professional, they are sure to perform better and stay with the hospital a long time."
In turn, a culture that encourages happy physicians and staff and respect for those who care for patients ultimately results in better productivity and patient care. "We have had patient satisfaction scores above the 90th percentile for almost three years," says Feuquay. "This is because when doctors come to work happy, they take good care of patients and people leave the hospital happy."
How to evaluate culture
"We try to be very clear when recruiting about how our group members interact with each other," says Cape Girardeau’s Foley. This includes expectations about how hard the group expects its surgeons to work, along with expectations regarding open communication and "camaraderie with other surgeons, and how we have developed a high-functioning team," he says.
Kevin N. Bartow, M.D., the newest physician partner with Cape Girardeau Surgical Clinic, says that the group’s executive team meets every Monday morning to check out from the weekend and review patients’ statuses. Bartow had done a rotation with the surgical practice and was aware of its openness. He suggests that physician candidates ask plenty of questions when discussing opportunities with potential groups. "For example, do you have policies that outline benefits for all physicians? How is work distributed?" He also suggests inquiring about compensation for the next two to five years. Holt advises to also ask about details regarding how compensation is distributed and whether any component of compensation is based on production.
It may help to ask how physicians in a group practice assign new patients to physicians, along with how new physicians contribute to strategies and decision-making in a practice or hospital. Other considerations include consistency of policies and procedures and how they’re applied. Often, talking with the practice administrator as part of the process provides clues to communication, governance and decision-making.
Lee recommends that a potential hire come back after the initial interview and shadow the physicians for a day to see what the practice is like. "But even if you can spend an afternoon with someone" she says, it is helpful to get a feel for the culture.
At the very least, candidates should be sure to speak to as many physician peers as possible. "For hospitalists, make sure you meet other hospitalists and ask them questions," Feuquay says. "Meet other subspecialists and ask them questions." He says the hospital tour often gives potential hires a chance to see how others perceive the hospitalist group, which can be a selling point for applicants.
Throughout your interview, tour and site visit, observe communication and interactions. "Pay attention to the way the physicians interact with one another, with nurses, specialists and managers," says Nordvedt. "How is everyone working together, and how do others achieve the work/life balance outside the hospital?"
Sometimes it is tough to identify signs of low morale, physicians who anger easily or hidden hierarchies, but the more people you talk with and the more time you can spend touring and visiting hospital or practice locations, the more likely you can spot signs of cultural fit. How employees treat patients, vendors or one another may provide clues to how organized, hectic or stressful the culture is on a typical day, and whether everyone buys into the mission and vision of the organization.
Owen J. Dahl, MBA, FACHE, of Owen Dahl Consulting in The Woodlands, Texas, says he advises asking for meeting minutes if possible, or at least to review a meeting agenda from group practices or medical staffs. "Notice if the agenda focuses solely on finances." He says there may be nothing wrong with that, but if the first agenda item focuses on patient quality of care, that sends an altogether different message than if every agenda for the quarter focuses on finances. It’s up to the candidate to decide which type of message or value fits with his or her beliefs, styles and vision for this new opportunity.
Feuquay recommends asking for a tour of the hospital and town. All candidates who visit his group have a tour of the Flagstaff area with a group member’s spouse, who is a real estate agent. Finally, remember to be observant not only throughout the planned activities, but during your entire site visit. So many clues to the potential employer’s culture are better ascertained through observation. As soon as you arrive, observe the feel of the waiting room and check-in or admissions area. Dahl suggests noting details such as whether notes and signs that inform patients about payment and policies are professional in appearance. If your tour takes you into clinical areas, observe nuances such as lighting, cleanliness and organization. Even the employee break room atmosphere might give a clue about the culture.
One of the best ways to assess cultural fit is to evaluate the intangible feelings you have when making the recruitment visit. Lee encourages physicians to go with their guts. "We try to make decisions based on finances and hours and such, but I think you also need to go a little bit with your gut and where you think you will have the best time," Lee says. "You are going to be spending a lot of time at work, and you need to genuinely enjoy the folks you are working with."
Teresa Odle is a frequent contributor to PracticeLink Magazine.