Cultural Fit: Your Physicians Care More Than You May Think

Once a physician has stayed with a practice for five years, the likelihood of him or her leaving is negligible—but turnover rates for those first five years can be high, according to the 2011 Physician Retention Survey from the American Medical Group Association and Cejka Search. In that survey, turnover was:

• 14 percent in the first two years after a physician first joined a practice
• 11 percent for the next two years
• 8 percent between years three and five

What drives that level of turnover? The nationwide, multi-specialty Organizational Culture Survey we conducted with Cejka Search in 2012 suggests that “cultural fit” is a prime driver of physicians’ satisfaction and dissatisfaction with their jobs.

A Prime Driver in Recruiting and Retention

The more than 2,200 physicians who responded to our survey rated the importance of cultural fit to their job satisfaction at an average score of 8.4 (on a 10-point Likert scale—but only 7.0 in terms of their perceived cultural fit in their current jobs. Clearly physicians perceive cultural fit to be important—and a fairly high percentage don’t feel they fit, or fit optimally, at their current places of employment.

“Cultural fit is a determining factor in a physician’s decision to join—or leave—a practice,” said David Cornett, senior executive vice president of Cejka Search. “Because turnover and prolonged physician vacancy can cost a practice as much as $100,000 per month, organizations can achieve significant returns by investing in the assessment and cultivation of cultural fit.”

Almost half (48.5%) of physicians responded with a score of 8, 9 or 10 that a lack of cultural fit prompted them to leave a practice or job, and almost two-thirds (61.9%) likewise said that their expectation of cultural fit was a determining factor in their accepting a practice or job opportunity.

Perception Versus Reality

A companion study of healthcare administrators found that while they have a reasonably good sense of what is important to physicians’ satisfaction in terms of organizational culture, they significantly underestimated cultural fit as a driver in terms of recruiting and retention.

• Asked if lack of cultural fit had been a determining factor for not extending an offer to an otherwise qualified physician candidate, administrators indicated that had been the case 36% of the time, on average. Yet, when physicians were asked if their expectations around cultural fit had been a determining factor in accepting a practice or job opportunity, the average score was 7.7, showing that cultural fit was a significant factor in evaluating prospective opportunities.
• Asked how often cultural fit had been cited by voluntarily departing physicians as a primary reason for leaving a practice or job, administrators responded that it was a factor 32% of the time, on average. However, physicians, when responding to the question regarding their agreement or disagreement about whether lack of cultural fit had prompted them to leave a practice or job, showed an average score of 6.5, indicating that more than 50% felt this was the case.

Organizations that underestimate the importance of cultural fit, do not accurately assess cultural fit in candidates, positively convey their practice culture, and then support the enculturation of newly recruited physicians place themselves at a significant recruitment disadvantage and higher risk for turnover.

Mission & Values Versus What Really Matters

Your organization may have worked long and hard to develop a clear mission and values—but, you can’t assume that mission and values translate into a culture that will attract and retain the type of physicians you want.

While clear mission and values was deemed important by the physicians surveyed—it was among the lowest ranked cultural attributes. Indeed, the top cultural attributes cited by physicians were:

• Respectful communication (8.6 average score)
• Patient-centered care focus and supportive management approach to errors and mistakes (tied at 8.5 average score)
• Transparent communication (8.4 average score)

”The study clearly shows areas of disconnect between what physicians look for and what they find—and what organizations think they provide,” said Dan Whitlock, MD, MBA, VITAL WorkLife consulting physician. “At a time when physician engagement is of paramount importance and healthcare organizations seek to promote satisfaction and loyalty, closing these organizational culture gaps can have a strong positive impact.”

Developing a Culture That Works

Start by creating a list of cultural attributes that are present or desired by your organization. You may want begin with the ones used in our survey.

We developed our list of cultural attributes by reviewing several standardized survey instruments which were developed for healthcare organizations. We then narrowed the attributes down to the 14 which we felt were most applicable to physicians and reflected the experience we have working with physicians and healthcare organizations.
Ranked by order of importance to physicians surveyed, those attributes were:

1. Respectful Communication
2. (Tie) Patient-Centered Care Focus
3. (Tie) Supportive Management Regarding Errors and Mistakes
4. Transparent Communication
5. Open Dialogue Across Roles
6. Team-Focused Environment
7. Collaborative Leadership
8. Clearly Defined Accountability
9. Adapts to Change Readily
10. Clear Performance Expectations
11. Compensation Plan Alignment with Mission and Values
12. Innovative Approach to Medicine
13. Clear Mission and Values
14. Objective Performance Evaluations

There may be other attributes which resonate with your physicians. Add them to your list. Share the results, then ask your physicians to help you prioritize where to begin the process of change, based upon the biggest potential impact, or the biggest gaps between expectation and reality.

Identify the key stakeholders and potential change champions. Think broadly, but make sure physicians are involved—and, potentially, leading—subsequent efforts. Look at the cultural attributes you’ve identified, and then think about who can have an impact.

For each cultural attribute, ensure that there is agreement about what it is, and the day-to-day behaviors and actions that support it at the individual, workgroup and organizational levels. This will help greatly in measuring results and helping hold stakeholders accountable for results.

Be Deliberate in Your Approach

After prioritizing, pursue the one or two attributes that will have the highest impact, and follow a defined path toward achieving meaningful and positive change. Do not let this initiative die in committee—set tangible benchmarks and accountabilities, and develop formal action plans.

Then, develop a roadmap on what needs to change, communicate it and act on it. Allow no exceptions. Make it as tangible as possible, and provide tools and resources to support those who are impacted.

• Ensure that physicians are involved in decision-making at every step, and if possible, leading key initiatives and activities.
• Provide training to leaders on how to identify and address barriers effectively.
• Discuss the initiative openly, at the individual and group level, including physicians and key stakeholders. Sometimes outside facilitators can be helpful in encouraging openness and creating a safe environment to share ideas and concerns.
• Provide individual coaching and mentoring for those who need more help or who are struggling. Holding all accountable will be key—in particular, those who have not been held accountable in the past.
• Measure progress periodically and adjust tactics, as needed. Communicate results honestly and constructively.
• Provide training and education on areas that support the change, e.g., communication skills, civility and behavior coaching, conflict management, coping skills around stress and burnout, developing resilience around change.
• Be willing to acknowledge when a physician is a bad fit, and act on it, respectfully and fairly.

Provide adequate time for your physicians to work on change initiatives. Simply adding committee meetings and additional work without placing value (monetary or otherwise) on the time and initiatives developed will be counterproductive.

When significant progress has been made around the first one or two cultural attributes, start on the next priorities.

Institutionalize the Cultural Attributes

Organizational culture also needs to be reinforced and nurtured. Recruit for cultural fit. Develop assessment tools and processes to ensure that physician candidates understand the organizational culture and demonstrate their ability to fit in and support the culture.

Use behavioral interviewing techniques to drill down with candidates regarding such things as conflict management, teamwork and communication—making sure they tie clearly into the desired cultural attributes.