Director’s Corner: Addressing lousy employee satisfaction scores

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Dear Director,

The results of the hospital’s annual employee satisfaction just came back and the ED didn’t score well.  I’m frustrated the efforts the nursing director and I are making weren’t recognized and I’m afraid the hospital will think I’m not doing my job. What should I do?

Hospitals typically conduct large, professionally performed surveys of their staff every 12 to 24 months. Hospitals commit time and money to these surveys for numerous reasons.  They clearly want feedback from their staff so they can be a great place to work, which impacts staff retention.  Hospitals may be seeking feedback on pay and benefits, if nurses get time for lunch breaks, patient safety, patient flow, staffing, interaction with the physician team, and how managers recognize top performers and handle underperformers.  But these surveys also help hospitals meet Magnet and patient safety requirements for awards or recognition the hospital may be seeking.


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Emergency physicians are generally pretty competitive people and like to do well.  Whether it’s a patient complaint, seeing our personal or group metrics below expectations or getting bad news on an employee survey, I recognize that we all take it personally and that it can be hard to accept the position we’re put in.  Your concerns about the hospital administration’s perception or the staff not recognizing what you’re doing is valid, but you should not let those concerns define you.

I’ll be the first to admit that I’ve been known to dwell upon bad satisfaction surveys for days and my mood can be impacted for a week or two when I’ve been called in by my CEO and told about “issues” with my department.  While some denial and anger about negative feedback is normal, you need to set aside those feelings so that you can professionally review the issues and come up with an action plan. You should also recognize that there’s usually a kernel of truth in any negative feedback we get.


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Dive in to the data

The great thing about these hospital surveys is there’s usually a lot of data and prior results for comparison.  I won’t begin to argue with the statistical validity of the results, but it is helpful to review each question and get into the weeds of response rates and top box analysis so you can better understand your issues.  Then compare these data points to previous years.  Sometimes the number of responses is so low that just a few low scores can significantly impact the average and even a small drop in average can sometimes have a huge impact in percentile.  Be sure to review any comments that might be associated with responses.  These might be helpful in understanding where the issues are and may also give you an idea of who wrote them.  There are likely some vocal staff members who use these opportunities to bring attention to an issue they might have brought up previously, but felt it wasn’t addressed adequately.  Sometimes people have an ax to grind and these surveys are a great opportunity to vent.  Common themes of employee dissatisfaction surround staffing (who doesn’t want more staff?), poor patient flow, fears of getting in trouble if an error is made (patient safety) and if the management team does not deal effectively with underperformers (managers need to own this one).

There are typically questions asking about nurse-physician communication and interaction.  While you can take great pride in high scores in this category, you should be appropriately concerned if the scores are low.  Hospital administrators want to know that the ED has a team atmosphere. Disruptive physician behavior or an environment of poor communication between nurses and physicians can lead to bad outcomes.  Be prepared to conduct your own 360-degree evaluation to get individual physician data that may clarify any specific issues regarding communication, approachability and professional respect.

Talk to others around the department

We all have our trusted confidantes around the department and poor survey results may be a situation where you consider talking to them.  Hopefully, since these surveys usually involve non-physician staff (nurses and other ED staff), you’re starting with your nurse manager.  From there, there should be conversations with other nurse leaders and your physician leaders.  The tone cannot be confrontational but rather trying to understand the results.  I’ve had people tell me they’ve given undeservingly low scores to something like staffing because they thought it would help with budgeting for more staff.  In reality, this only leads to meetings with the c-suite explaining why the staff seems frustrated with the budgeted staffing models.

Next Steps

By now, you should be past the denial stage and into acceptance.  You’ve also done enough research to have a sense of any true problems.  It’s at this point where it’s critical to put the data together, take some time for self-reflection and try to make an honest assessment to find the kernel of truth in the survey results. At this point, you need to consider if your energies have been focused elsewhere and not addressing what the staff identified as problems.  This is also the time to consider other indicators of employee satisfaction such as staff retention or turnover.  Low turnover rates are usually a sign of a satisfied staff.  Also look at recruitment and vacancy rates.  If recruitment has been difficult and vacancy rates are higher than normal, the staff may be overextended.  Compare recruitment and retention rates to the feedback you received regarding staff morale and ED mood from nurses and fellow docs.  Does one support the other or are they misaligned?


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It’s now time for some staff meetings.  I think it’s important to share the results with the staff. After all, it’s their department as well and they should accept some of the responsibility for the results and have input into the solutions.  These should be done side by side with the nurse manager whether you’re meeting with the docs or the nurses.  Again, these can’t be confrontational, but an attempt to hone in on problems and identify solutions.  It’s fair to say that your doors are always open and you’d rather have people bring up issues as they occur throughout the year so you can address them than to bring them up during a blinded survey.  During this meeting, you don’t have to lay out future plans and you shouldn’t make false promises. Yes, we will get budgeted for more staff next year sounds like a fake campaign promise that may not be deliverable.

Communication going forward is critical.  This may involve more staff meetings, daily or weekly emails and/or poster boards in the lounge.  Everyone should know the department’s goals and what steps are being take to achieve them.  It’s also appropriate to discuss challenges and have teams work on solutions.

Finally, there may need to be some staffing changes.  I’ve seen satisfaction scores bounce up or drop considerably based on staffing changes. Sometimes, it’s about having doctors not complain and feed the fire of staff frustration. It’s the rare site medical director who also supervises nurses, but certainly working with your nursing leadership to offer whatever assistance is necessary. Sometimes just being a sounding board and making some HR suggestions can be a huge help.  If your evaluations show that low satisfaction scores may be a provider issue, you’ll need to manage them.  The providers need to be the leaders of the department and leading involves addressing problems and working to keep morale up. It’s our job as leaders to model the behaviors we want in our staff.

Conclusions

Having an emotional personal stake in employee satisfaction results (or any other metric that evaluates the ED) is a good trait in a medical director.  It’s important to get over any anger or denial that may come with negative feedback and spend time analyzing the results and looking for opportunities for improvement.  Be sure to take in the full picture of the department. This can be assessed by understanding the mood of the department and examining recruitment and retention.  It also may involve recognizing that one or two providers with negative attitudes can reflect poorly on all of the providers.  Communication to the staff, as well as the hospital administration, can insure that everyone is aligned with the goals and the solutions.

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

3 Comments

  1. “Disruptive physician behavior… ”

    Be aware this feeds into 2 cognitive biases:

    1. Disruptive people may be your best friends as they see how things could be instead of how they are.
    2. Physicians are not the only ones who are disruptive; nurses can be disruptive as well. This behavior may be passive-aggressive: “Have the doctor do it.” As the physician lacks the “no” card, any physician push-back may get her labeled “disruptive” when, instead, she is being efficient, having people work to the top of their licenses.

    • Mike Silverman on

      Thanks for reading the column and leaving a comment. I have a few columns that address that. Click on the director’s corner link under the “columns” tab. I’ve written on nurse retention, working with your nurse manager, and several others on communication.

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