​​​By: Perreira, T., Prokopy, M., Moshirzadeh, E., Shea, C. 

Enhancing the relationships between hospitals and physicians cannot be achieved through a single program, tool, or one-off engagement exercise, it demands a long-term commitment to working with both parties to inform sustained and continuous organization and system development, resilience, and improvement. 

For over a decade, Ontario Hospital Association (OHA) members have expressed a desire for shared learning to nurture positive physician engagement and improve hospital-physician relationships. Remaining a long-term focus for the OHA, in 2017 the OHA partnered with the Institute of Health Policy Management and Evaluation (IHPME) at the University of Toronto's Dalla Lana School of Public Health (DLSPH) to advance our work in this area. Dr. Tyrone A. Perreira, joined the team as an Applied Research Scientist and remains an Assistant Professor with IHPME. Dr Perreira specializes in Health Services Research, Organization and Management. He collaborates with healthcare leaders at local, national, and international levels to better understand and apply systems thinking when trying to address complex problems.  

Existing research on health care reform highlights the importance of physician engagement as a critical factor for developing and implementing effective models of care, improving efficiencies, quality of care, patient safety and satisfaction, and provider satisfaction and retention. Systemic and work environment factors including resource constraints, efficiency drives and consequent increases in stress, make it challenging for senior hospital administrators to create and sustain work environments that support and empower physicians. 

What do we mea​n when we say physician engagement?

During early conversations with administrative physician leaders in hospitals it quickly became apparent that there was a lack of clarity regarding the term 'physician engagement.' Hospitals were using terms like “participation in" and “satisfaction with" to define and measure what they referred to as “physician engagement". Some hospitals were struggling with how to identify measurable objectives to track improved engagement over time. These conversations in early 2017 identified numerous disparities and we recognized the need for us to better define and therefore allow us to measure hospital physician engagement. With this information we could then begin to accurately develop and implement engagement strategies. 

Two seminal pieces of research, the foundation for our current work, included a scoping review and conceptual analysis of the term 'physician engagement.'  We identified that the term 'physician engagement' refers to regular participation of physicians in (1) deciding how their work is done, (2) making suggestions for improvement, (3) goal setting, (4) planning, and (5) monitoring of their performance in activities targeted at the micro (patient), meso (organization), and macro (health system) levels. This is quite different when compared to physician 'work engagement', which refers to a physician's positive, psychological state of mind, characterized by vigor, dedication, and absorption in their clinical work. (Schaufeli, W. B., Bakker, A. B., & Salanova, M. (2003). Utrecht work engagement scale-9. Educational and Psychological Measurement. ) 

Survey Development and Pilot Testing

Given that there was not a shared understanding or definition of the term “physician engagement" and no helpful measurement tools, we identified an opportunity to develop a simple and efficient tool to accurately measure physician engagement to facilitate well-informed decision-making by hospital leaders using the results. 

In collaboration with the Ontario Medical Association, Ontario Health, IHPME at DLSPH, and with the support of the OHA's Physician Leadership Network, we started developing and piloting a short instrument to measure physician engagement. The survey, which was completed anonymously through an electronic link, took less than five minutes to complete.  As we gained a better understanding of member needs, the survey continued to expand. Dr Perreira invited his colleague, Dr. Christine Shea to collaborate on the design of the survey.  Dr. Shea is an Assistant Professor (Teaching Stream), Program Director for the MSc Quality Improvement and Patient Safety and teaches across IHPME on leadership and change. The final survey tool titled 'Physician Engagement, Wellbeing and Organizational Culture Survey' measures physician participation in leadership activities, work engagement, psychological empowerment, wellbeing, hospital-physician relationships, perceptions of leadership, perceptions of work environment, and perceived quality of care.  

Physician Engagement, Wellbeing and Organizational Culture Survey

In 2019, Ontario hospitals were offered the opportunity to participate in the Physician Engagement, Wellbeing and Organizational Culture survey, free of charge. We worked with the Canadian Society of Physician Leaders to do additional testing with 1096 physicians from 9 Provinces. 

Outcomes and Benefits of the Survey

Participating Ontario hospitals each received two reports.  First, an individual site colour-coded report which identified areas of strength and areas for improvement. Sites were able to measure their scores against all participating hospital sites through an aggregate provincial report.  Several sites used their outcome reports, as we intended, to help determine where to focus their efforts and resources in prioritizing initiatives. A final report was created with key recommendations.   

Back by Popular Demand

In 2021, we received numerous requests from the initial participating sites to re-administer the survey.  These sites were offered the survey once again.  This allowed for comparison with their first pre-COVID survey data. We were able to categorize sites based on their scores in the survey; (1) Gold standard sites had positive scores, both years, in all categories; (2) Sites demonstrating significant improvement in 2021, compared to 2019; and (3) Sites demonstrating no change with scores remaining low in all categories, both years. 

Qualitative Research

To deepen our understanding of our Physician Engagement, Wellbeing, and Organizational Culture Survey data collected between 2019 and 2021, our research team developed a qualitative study to further explore hospital-physician relationships. The study was designed to specifically examine barriers and facilitators to hospital-physician relationships and the current state of equity, diversity, and inclusivity in healthcare leadership. 

Between May and July of 2022, a diverse group of senior hospital leaders were interviewed by our research team. Hospitals varied in size and location. Participants varied by gender, job title, and clinical training. Titles of participants included, but were not limited to, CEOs, VP Medical, Medical Affairs, Chiefs of Staff, and Medical Staff Association Presidents.  As noted above, we aimed to collect rich information regarding participants' perceptions of the calibre of hospital-physician relationships, equity, diversity, and inclusion with a focus on women leadership in healthcare in their institution. With this information we can assess how well our proposed interventions are helping `improve working relationships between hospital leadership and frontline physicians. 

Findings: Helpful in Improving Hospital-Physician Relationships.

Sites that had high physician work engagement had several common characteristics: a positive, supportive work environment and organizational culture, in which colleagues tended to know each other outside of work, and regardless of title, pitched in to help each other when needed; respect and trust in leaders; clear and consistent communication; visible presence of senior leadership and willingness to answer questions on a regular basis; frontline physician input sought when making decisions that affected clinical work; high emotional intelligence in  leaders with demonstrated support for staff. 

Although there has been an increase in the number of healthcare leaders from minority groups, participants noted that healthcare leaders should not be complacent, believing that equity, diversity, and inclusion are prevalent. Implicit biases, sexism, and discrimination still occur. Participants identified a clear need to have further discussion on each of these topics and acknowledged that there is always opportunity for improvement. Participants noted that both males and females are responsible for actively targeting talent, while creating and identifying potential leadership opportunities. There needs to be accountability and responsibility for both sponsorship and mentorship. Planning and policies are required to avoid interruption of leadership pathways due to parental leaves.   Mentorship pathways and opportunities for new leadership need to be created. This study is soon to be published.  

On The World Stage

Our research has received global attention and recognition leading to several ongoing international collaborations. Our research has been presented in Quebec, the United States, and the United Kingdom.  

Our research has helped us to gain insight in several areas: (1) organizational barriers to physician engagement; (2) key activities for effective healthcare leadership; (3) critical leadership competencies; and (4) the importance of physician engagement to inform and optimize future models of care. 

Additional Research on Engagement in Quality Improvement

We carried out a survey of Ontario hospital physicians. Both the Ontario Medical Association (OMA) and the Ontario Hospital Association (OHA) included an e-link to the survey in each of their November 2021 newsletters. There were 231 Ontario certified physicians that participated in this inaugural survey, with majority of respondents practicing in hospitals followed by independent practices and Family Health Teams. We gained insight into key challenges to participating in QI identified by physicians. Based on these insights we have proposed interventions for leadership to begin to address these challenges and better support physicians in their efforts to improve healthcare quality. This study is soon to be published.