Tyrone Perreira PhD, MEd, Melissa Prokopy, LLB, and Tamarah Harel
The concept of physician engagement is important to every hospital for a variety of reasons; however, a literature review revealed that no universal definition of the term exists. A conceptual analysis helped define the concept for further development and began to establish a common language. We clarify both what physician engagement means and how leaders can measure engagement. Establishing a common understanding will focus improvement efforts and allow organizations to compare their engagement results and strategies over time.
KEY WORDS: physician engagement, definition, measurement, common language
A recent conversation with a well-respected hospital physician leader revealed his frustration over effectively engaging physicians working at his hospital. Many of them struggle with burnout and transitions, such as the adoption of a new hospital electronic medical record system; an ever-increasing workload also adds to the burden. He knows these physicians are committed to providing the best possible patient care but cannot figure out how to boost engagement.
This conversation brought to light a bigger question: are these physicians truly unengaged, or does the term “engagement” need to be better understood and defined? Because “engagement” has often been applied to a variety of actions and behaviours, it is likely being used too broadly and inconsistently. Moreover, within Ontario’s health care system, a multitude of surveys are currently used to measure physician engagement.
The concept of physician engagement is important to every hospital for a variety of reasons — statutory obligations, accreditation requirements, to improve culture and relationships — yet no one seems to be able to clearly articulate what it means or how to improve it. Most importantly, without a clear and shared understanding of what the term means, organizations cannot be certain that they are using the right tools to capture what they set out to achieve. In turn, efforts to improve engagement may often not succeed.
With this in mind, the Ontario Hospital Association and the University of Toronto conducted a robust literature review of the term “physician engagement,” confirming that, currently, no universal definition or measurement exists.1 “Engagement” has been applied to a variety of actions, such as support for projects,2 motivation to take on leadership roles,3 improving organizational performance,4 participation in the appropriate and effective use of services,5 and an ongoing two-way social process in which both the individual and organizational components are considered.6 Physician engagement appears to be distinct from “work engagement,” which refers to a positive psychological state of mind characterized by one’s vigor, dedication, and absorption in overall work.7 Physician engagement also appears to be distinct from “job satisfaction,” a worker’s positive feeling toward their job.8 As such, one could potentially be engaged in certain aspects of work, organizational leadership for instance, but dissatisfied with other aspects, such as increasing documentation requirements. This is rarely unpacked in the literature.
The lack of a clear definition and understanding of engagement can result in vague survey questions. Leadership may misinterpret results, and dissatisfaction may manifest as a lack of engagement. The literature review plainly demonstrated that engagement can refer to a range of actions, attitudes, and behaviours.1 It also revealed that a work environment that includes a culture of accountability, communication, incentives, good interpersonal relationships, and opportunity can enhance physician engagement and result in improved outcomes.1
A conceptual analysis of the term physician engagement was then conducted to address this ambiguity, help define the concept for further development, and begin to establish a common language.9
Defining physician engagement
Based on this conceptual definition, one can see that a physician might be highly engaged in one area, such as direct patient care, but may have little interest or involvement in another, such as health system improvement.
Clarifying the “what”
This working concept of physician engagement offers a valuable starting point for organizations and their leaders to begin thinking about what they are truly trying to measure: engagement, job satisfaction, level of involvement, commitment? At what level? Perhaps the focus is work engagement, which applies to the physician’s state of mind and to their work overall, or it may be more about participation in specific activities. For the latter, it is vital to also determine the target of these activities: patients, the organization, or the health care system.
Homing in on what is being measured offers a clearer picture of how to begin the work of improvement by first choosing the right measurement tool. The appropriate tool should be valid and reliable. This can inform the development of a sound improvement strategy. Although this concept seems simple and straightforward, anecdotal evidence suggests otherwise. For example, a physician who attends leadership meetings is not necessarily engaged. In this case, it is more valuable to ask why that physician is in attendance and if they genuinely want to participate. More specifically, are they contributing to the discussion about how work should be done, suggesting improvements, helping set goals, and planning and subsequently monitoring performance?
Because no universal definition or measurement currently exists, even hospital leaders who are confident in their engagement data may benefit from taking a closer look at their organization’s current assessment of physician engagement. Although a hospital may have good baseline data and trends that show improvement over time — which is a great success on its own — having a clearer understanding of what is being measured can be useful in supporting the goals of the organization.
Clarifying the “how”
Improving engagement over time requires a concerted effort by health care leaders to evaluate their objectives and the methods used to achieve them. Those in leadership positions should consider the language used, the extent to which they want their physicians involved at each level (micro, meso, and macro), and how they measure engagement. Talking to physicians and gathering qualitative input is critical. Some leaders believe that physicians who don’t complete surveys are often the least engaged; however, these physicians may be convinced that their participation will not bring about any positive changes. Success will only be achieved if organizations commit to working together with physicians.
Hospital leaders can begin their improvement efforts by taking steps to set up their organizations for success, namely:
Define your objectives — What do you want physicians to be engaged in? At what level?
Be explicit — If you are only interested in participation in a specific activity, then clearly state that.
If conducting a survey, use a tool that is valid and reliable.
Work with peer hospitals to use a common tool — This allows for comparisons and sharing of improvement strategies among sites and jurisdictions.
Do more than surveying — Qualitative data are equally important in clarifying the “why,” i.e., the facilitators and barriers to engagement.
Consider a physician compact — A joint agreement between your organization and its physicians can explicitly outline what physicians may expect from you and, in turn, what you may expect from your physicians.
Encourage and create a work environment that includes a culture of accountability, communication, incentives, good interpersonal relationships, and opportunity.
The next time you hear the term physician engagement, reflect on how it is being used. As most health care leaders use the term engagement to denote action, a consistent approach offers an opportunity to realign and implement standardized language across the sector. Agreeing on a common approach is ideal to enable a more comprehensive investigation and understanding of physician engagement. Moreover, establishing a common “what” will assist organizations by focusing improvement efforts in a targeted way and allow organizations to compare their engagement results and strategies over time.
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8.Bowling NA, Hammond GD. A meta-analytic examination of the construct validity of the Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale. J Vocat Behav 2008;73(1):63-77.
9.Chinn PL, Kramer MK. Theory and nursing: a systematic approach. Maryland Heights, Mo: Mosby; 1983.
Melissa Prokopy and Tyrone Perreira both participated in the conceptualization of this article and revisions.
Tamarah Harel assisted with revisions and organization of the article. All authors approved the final version.
Conflict of interest: The authors declare no conflict of interest. No funding was received for this work.
Tyrone Perreira PhD, MEd, is an assistant professor at the University of Toronto’s Institute of Health Policy Management and Evaluation and an academic consultant with the Ontario Hospital Association.
Melissa Prokopy, LLB, is the director of Legal, Policy and Professional Issues at the Ontario Hospital Association and was appointed adjunct faculty at the University of Toronto’s Institute for Health Policy, Management and Evaluation.
Tamarah Harel is a public affairs specialist with the Ontario Hospital Association.