Overview

The costs and time associated with recruiting a practitioner to your community can be quite overwhelming. Retention, therefore, is not only important for the health and well being of the community, it is good for economic reasons. Also, the credibility of a site is directly affected by continuity of providers. A perception of frequent turnover is disastrous for a center and its patients.

In this chapter we highlight strategies for increasing the potential for the retention of your health professionals and review factors that effect career satisfaction among NHSC providers.

Success in retention should be an important goal for the community and one that is accompanied with a specific plan of action. The retention plan needs to hold individuals responsible for select activities and for ensuring that the plan is ultimately followed or modified as necessary. While the Search Committee can initially accomplish this work, over time it should be delegated to your site's Executive and Clinical Directors with oversight from the Board Personnel Committee.

RETENTION THROUGH RECRUITMENT

Retention starts with the first contact with a prospective candidate. Turnover studies indicate that a large number of separations occur shortly after employment, due to the false representation of the position or community. Therefore, it is critically important to be completely forthright. While you want to portray the community at its best, you do not want to disappoint a candidate who has expectations that cannot be met. It is also important to stress to a candidate that retention does not mean a lifetime commitment.

Retention also is enhanced when the "right" candidate is selected for the position. The closer the match between the candidate and the community, the longer s/he is likely to stay. Consequently, it is important to find an individual whose personal, professional and environmental needs closely match what a community can provide. Refer to Chapter 11 for factors to consider during recruitment to increase the likeliness of a successful match. The lesson here should be obvious; "front-end" recruitment mistakes will inevitably lead to more difficult retention challenges on the "back-end." Careful recruitment is by far the most important principle of retention.

COMMUNITY INVOLVEMENT

The community can assume an active role in retaining primary health care professionals by assisting the candidate and his/her family in integrating into the community. Integration activities can include:

• Media coverage about the arrival;
• Invitation to social events;
• Involvement in community activities; and
• Introduction of a "buddy" system for the provider's spouse/ partner.

It is important that the new community member feel wanted and needed, especially during the difficult transition period of moving from one community to another. While it is important that the candidate be greeted warmly, there is a balance between socializing and the need for privacy; the community needs to maintain the appropriate balance. Too often, communities fail to respect a health care professional's need for privacy.

REASONS FOR LEAVING

The NHSC found that the major factors affecting the clinician's decision to leave his/her assignment were:

• Administration, e.g., site director, policies and procedures, communication, etc.;
• Salary and benefits, e.g., compensation too low, no incentive plan linking income to patient volume;
• Personal factors, e.g., amount of time with family, lifestyle, safety issues, social and educational opportunities, spouse/partner happiness; and/or
• Obligation, e.g., completion of NHSC scholarship and/or loan repayment obligation.

Other reasons for leaving a site include the following:

• political atmosphere in group
• community atmosphere/culture
• retirement
• desire for solo practice
• location of practice
• lack of social opportunities
• lack of on-call coverage
• professional isolation
• economy of community
• climate
• lack of hospital facilities
• insufficient practice volume
• privacy issues

It will be important to develop a plan of action addressing those factors that fall within the community's span of control. This will minimize any adverse effect they might have on the professional.

This list can also serve as a discussion document between the community/employer and the professional. By discussing some of the common reasons practitioners leave, the community/employer may be able to employ preventive strategies before the factor leads to a decision to move out of the community.

RETENTION GUIDELINES

There are a number of guidelines that should be kept in mind when striving to improve retention of health care professionals:

• Orientation - A well-planned orientation is designed to help an individual feel welcomed, less apprehensive and more knowledgeable about the new environment and position. It is important to orient the person to the position as well as the other health care providers and other health resources in the community. Possible contents for a formal orientation program are included in Exhibit 12-1.

  An effective orientation process needs to be well planned and thorough. A key factor is to determine who will be involved. Try to include a variety of people and groups from both the organization and the community. Each group will bring a different perspective on the role and function of the position.

  The length of time it takes to orient a new practitioner will depend on the position within the organization or community and on the individual. In the case of an existing facility with a program, an effective orientation period can range from two to three months. In the case of a solo practitioner, it will take about three to six months before the new person is able to be proactive and actually have an impact on the health of the community.

  In some communities, a mentor or buddy system is helpful to orienting the new practitioner to the role and the community. Defined as a wise advisor, teacher or coach, a mentor is someone who can play a critical role in the formal and informal socialization of a practitioner. The mentor can inform the new recruit about the unwritten rules, regulations, policies and procedures. This "insider" viewpoint is best received from:

  • someone who has been with the community/organization for sometime and is perceived as competent; or
  • a potential confidant and a non-threatening person.

  The mentor should be determined in advance and introduced to the new practitioner within the first week of arrival. Bi-weekly meetings for the first three months and monthly meetings thereafter for at least the first year should be scheduled. It is probably more effective to keep the meetings informal, addressing information needs as they arise.

  Most orientation programs fail as a result of either of the following reasons:

  1. The newcomer receives too much information too soon and cannot retain it; or
  2. The program becomes too time consuming and consequently is delegated to junior personnel or in some cases not completed.

  This can usually turn the program into a paper exercise rather than a process for gaining valuable information.

  In addition to internal onsite efforts, look to the NHSC for ongoing orientation in terms of what support is available to the sites for their retention efforts.

• Network Development - Health care providers are in need of professional companionship as well as consultation. For this reason, it is important to assist the practitioner in developing the types of relationships that will help to meet professional needs. This can be accomplished by:
  • introducing the new person to the other health care professionals in the community;
  • hosting a local professional association meeting;
  • paying for membership in relevant associations;
  • paying for one or more educational conferences per year; and
  • securing an affiliation or teaching position with local universities or health programs.

• Performance Appraisal - The continuous process of feeding back to a person, information about their performance is critical to ensuring desirable behavior. Consideration needs to be given to both the informal and formal aspects of performance appraisal. Informally, the new practitioner will need to hear with some regularity about how his/her work is being perceived by others (i.e. managers, community, patients). A system will need to be established for providing this type of feedback in a non-threatening but direct manner.

  A system to review performance semi-annually or annually needs to be developed. This system of appraisal has several objectives:

  • It lets the practitioner know formally how their performance is being rated;
  • It enhances communication between the evaluator and the practitioner;
  • It identifies those individuals where compensation increases or bonuses are warranted;
  • It locates individuals that require additional training/education; and
  • It plays an important role in identifying staff members who are candidates for promotion (if appropriate).
• Ongoing Contact - Given the importance of recruitment, it is suggested that the committee or a designate have ongoing contact with the new recruit. Also, it is important to maintain "continuity of contact" between the NHSC program, the site and providers. The purpose of this contact is to ensure that the individual and his/her family is adjusting to the community, as well as to identify any problems that might arise during transition. This ongoing contact can take the shape of regularly scheduled meetings over lunch or dinner to talk about how "things" are going. When issues are raised, the committee representative can be proactive in ensuring speedy resolution.

• Community Integration - Socialization does not take place overnight. It requires continual interaction between the community and the practitioner. Its importance cannot be overemphasized. An individual who has been effectively integrated into the community will be more loyal to its citizens and will likely stay longer within the community than if s/he had not been integrated. It is also important to include the family in the integration process. Integration reduces a newcomer's anxiety and uncertainty, and will contribute to his/her satisfaction with the new position. Activities that can assist with integration include:

  • a tour of the community;
  • introductions to community leaders;
  • a community/neighborhood reception;
  • arrival announcements in the local papers that are circulated to appropriate referrers and users; and
  • dispatch of the welcome wagon program.

  Community members should go out of their way to include new providers in social situations, community events or one-on-one interactions, e.g., fishing, camping or hiking, which introduce the individual to the lifestyle of the community.

• Professional Development - It can be easy to forget the importance of professional development to practitioners, especially in areas of solo practice. To do so is a mistake. Research has shown that a highly educated work force is likely to remain interested in developing skills and knowledge over an entire career. Benefits should include membership in professional organizations. Often this is overlooked and contributes to isolation of the providers.
• Recognition Programs - Recognition and rewards are often closely linked to the satisfaction level that an individual feels towards his/her job, community or employer. For this reason, it is important that consideration be given to how an individual is to be recognized and/or rewarded for successful performance. Some rewards are more obvious such as salary, benefits, bonuses and promotions. These rewards can be handled through an annual review process. Other rewards are intrinsic in that they pertain to an individual's feelings of competence, responsibility, personal and professional growth and career development. These rewards are less tangible in nature and depend on the needs of the individual practitioner. Each practitioner and employer will need to work together to define those factors that are important to the practitioner and to identify activities to ensure that these rewards are realized.
• Retention Checklist - Exhibit 12-2 summarizes a checklist of items that should help you attend to matters that have been found to be most effective in assuring provider retention. The checklist is meant to cover the retention of all primary care professions, not just physicians.

SUCCESSFUL RETENTION STRATEGIES

Chapter 3 includes case studies of five primary care centers that have been relatively successful in recruitment and retention. Although some of the principles and techniques they apply to retaining professionals may differ, they share some common beliefs. The administrators agreed that the highest priority should be the happiness of the family. Professionals satisfied with their practice will choose to leave if their families do not enjoy living in the community.

In terms of satisfying the practitioner, the administrator must keep two things in mind: flexibility and opportunity for input. The following suggestions are recommended to assure the professional that his/her needs are important:

• Give as much flexibility as possible in call coverage, work schedules, and style of practice;
• Sites must be prepared to try things differently and take risks - the greater the autonomy the better;
• Consider decentralizing management functions, providing autonomy for health care practitioners, and including all health care practitioners as part of the management, e.g., dentist, mental health professionals;
• Accept input from the professional staff in both day-to-day operations and long-term planning;
• All professionals ought to play a significant role in board meetings and in the design of new or expanded sites; and
• Be aware of family/spouse/partner issues.
• Make sure providers have a network for referrals, especially in rural areas. Identify sub specialists who will accept indigent patients. Identify colleagues for sharing on-call duties;
• Keep salaries and benefits competitive with other facilities in the public and private sector;
• Monitor quality of facilities and equipment as well as the concerns of providers in order to maintain high quality health care and employee morale;
• Encourage and support continuing education opportunities, locally or onsite;
• Help foster personal contacts and social opportunities for providers through communications vehicles such as newsletters, online bulletin boards, and official and unofficial gatherings. An announcement of a provider's arrival in local newspapers may help smooth the transition to the NHSC site;
• Emphasize importance of providers' care to the community; give positive reinforcement for this decision to serve the underserved;
• Provide clear orientation on the procedures and policies of the site;
• Ensure that providers' training, skills, roles, and limitations are understood by all staff including the site director; keep staff informed about the role, responsibilities, and limitations of a site director;
• Conduct regular staff meetings to allow providers to voice positive and negative feedback and suggestions; take providers' input seriously and implement changes when appropriate and feasible;
• Ensure a work week that permits acceptable (to the provider) time off, limit on-call duty and allow and/or encourage health professionals to take time off for personal and continuing education reasons;
• Make sure providers are given a level of autonomy that they are comfortable with - not too much so as to intimidate them but not too little so as to frustrate them;
• Identify providers who are interested in becoming involved in the community, whether it is in health care or other types of activities, and foster development of their involvement;
• Help providers locate good quality, affordable housing within a reasonable (according to the provider) distance from the site;
• When relevant, explore options for providers' spouses who are pursuing careers, and children who need educational and social opportunities; and
• Conduct performance reviews; review the findings for trends or patterns that should be addressed; conduct exit interviews that cover the reasons for leaving.

In addition to the foregoing exhibits outlining elements of a thorough orientation program and retention checklist, the following examples may also be helpful to you. The first example (see Exhibit 12-3) is an outline for developing your own written site-specific retention plan. Please be aware that if you are a Section 330 Federally-supported Community Health Center, your project is expected to have a written plan that covers both recruitment and retention. The second example is a NACHC monograph entitled Physician Retention in Community Health Centers (see Exhibit 12-4) authored by the former president and CEO of the Southern Ohio Health Services Network (SOHSN). While this monograph focuses on 12 time-tested principles specifically directed toward physician retention, they are altogether consistent with and supplementary to the principles discussed in the foregoing narrative. As previously noted, the ideas, suggestions, and principles set forth in the chapter are meant to apply to the retention of all primary care providers that are within the purview of the NHSC program including physicians, physician assistants, nurse practitioners, certified nurse midwives, dentists, dental hygienists, and mental and behavioral health professionals.

As the health industry evolves, you can expect that your staff will have other employment options come their way from time to time even if they are not actively seeking employment elsewhere. You must therefore be vigilant to both recruitment and retention factors impacting on your entire staff - professional and non-professional alike. By doing so, you will hopefully be in a favorable position to avert avoidable service discontinuity and the attendant high cost of replacing personnel essential to your mission. In addition to assessing the satisfaction of your patients from time to time, you are strongly advised to periodically assess the satisfaction of your key employees as well. We hope the ideas, suggestions, and principles in the chapter will help you optimize your site's opportunities for staff retention.