9-411-018 REV: MARCH 2, 2011 ________________________________________________________________________________________________________________ Professor Boris Groysberg, Dr. Lisa Leffert, Assistant Professor, Harvard Medical School, Assistant Director Kerry Herman, Global Research Group, and independent researcher Libby Williams prepared this case. The authors are grateful to Neil Crimins for his contributions. Some data have been disguised. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. Copyright © 2011 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685, write Harvard Business School Publishing, Boston, MA 02163, or go to www.hbsp.harvard.edu/educators. This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School. BORIS GROYSBERG DR. LISA LEFFERT KERRY HERMAN LIBBY WILLIAMS Development and Promotion at North Atlantic Hospital It was late September 2009 and Dr. Elizabeth Harris, Chair of the Department of Anesthesiology (DA) at North Atlantic Hospital (NAH), took a last look over her department’s latest staff satisfaction survey results. A year ago, Harris had joined the prestigious teaching hospital as department chair. After years as a leading research physician and administrator at a large west coast university hospital, the challenge of running one of the largest departments at the nation’s leading medical center presented a rare opportunity. She knew the challenges, however, would be significant: her department was understaffed and overworked, morale was low, and high turnover indicated low engagement and a lack of commitment amongst her physicians. Further, although it was one of NAH’s largest departments, DA physicians—all faculty at University Medical School (UMS)—had one of the lowest promotion rates in the hospital. As Harris took stock of the department’s state, along with DA Vice Chair Dr. Lesley Cook, she administered a staff satisfaction survey to assess conditions. Early results confirmed that Harris faced some significant challenges, including a staff of physicians that felt overworked and undervalued, had little sense that the institution was aware of their needs in terms of professional development, had a low sense of workplace satisfaction and engagement, and struggled with issues of work/life balance. Further, many felt there was a perceived lack of transparency and fairness around the UMS promotion process; a perceived lack of clarity around the UMS promotion criteria; and a perceived bias towards investigators over clinicians and educators. Many physicians expressed concerns that the hospital and department leadership were unable to provide long- or short-term career guidance (Exhibit 1 provides select results from the survey). Historically high turnover in the department, signaling low commitment and engagement with their employer, confirmed the survey’s findings. A year earlier, NAH had taken some steps to address these issues by mandating that each department implement a career conference program. With no formal career conference program yet in place for the DA, Harris and Cook set about designing a career conference initiative; making it one of several initiatives Harris prioritized as a means to achieve her goals of improved staff satisfaction, higher promotion rates for her department, and enhanced performance across the department. The initiative faced several challenges and Harris knew she had a steep road ahead; she sat down to consider how she might augment her own department’s professional development programs and ensure their success. Would a career conference initiative address her department’s needs? What other factors should she consider in her efforts to address these needs? 411-018 Development and Promotion at North Atlantic Hospital 2 DA at NAH The Department of Anesthesiology (DA) was one of NAH’s largest services, with 200 physicians. Under its auspices, patients received a comprehensive range of clinical services, including perioperative anesthesia services, critical care, and pain medicine. Clinicians were involved in patient care in the obstetrical unit, the critical care units, in interventional treatments for pain management, and operating room locations in the departments of Radiology, Gastroenterology, Gynecology, Neurosurgery, General Surgery, Cardiology, and Pediatrics, as well as several off-site locations. Clinicians focused about 80% of their time serving patients and about 20% of their time was spent conducting research or engaged in administrative duties. The Department supported an extensive research program encompassing critical care and pain medicine, neurosciences, biomedical innovation, and ethics. Research physicians (also known as investigators) typically spent about 80% of their time doing “bench research” and a portion of the remaining 20% was spent treating patients, educating residents and medical students, and contributing to the department’s administration; approximately 30% of the physicians were researchers. Promotion at UMS Typically physicians were hired as Assistant Professors, and were put up for promotion to Associate Professor, depending on performance, within a variable amount of time (five-to-fifteen years). Promotion decisions considered regional and eventually national reputation, demonstration of scholarship and publications of research results, or for educators, educational materials that have been adopted locally, and eventually regionally or nationally. To become a full professor, a physician had to attain a national and international reputation, influencing research, education or clinical practice in a significant way. (Exhibit 2 provides a more complete description of the UMS promotion criteria.) Across the UMS hospitals, the promotion rate for all physicians was acknowledged as “low” when compared with national averages; this was especially true for the clinician and educator tracks. Recent changes in the UMS promotion criteria had attempted to improve successful promotion. To better capture the significant contributions of clinicians, educators and innovators and to create a more recognizable promotion path for clinicians, the importance of being an educator was stressed through all pathways (investigator, clinician and educator). Challenges To fully understand their department physicians’ concerns and possible remedies, Harris and Cook conducted interviews across a selection of DA faculty and peer NAH department senior leadership. Physician concerns were wide-ranging and fell across four major buckets: promotion process, work/life balance, giving and/or receiving feedback, and department culture. Promotion Process Across the board, physicians reported a lack of clarity around the UMS promotion criteria; a perceived lack of transparency and fairness around the promotion process; and, perhaps most troubling, a perception that promotion was not relevant to their own career. Most felt the promotion process was biased towards investigators over clinicians and educators. Development and Promotion at North Atlantic Hospital 411-018 3 Criteria One physician explained his confusion over the criteria for promotion: “It is not 100% clear what needs to be done to get to professor.” Another reported, “When I first got here, I looked at the criteria, thought it was clear, but then realized I couldn’t understand what I needed to do, and there wasn’t really anyone who could guide me.” Some physicians acknowledged that they had not yet seen the UMS Criteria for Appointment and Promotion booklet, which outlined criteria and sample metrics to fulfill promotion requirements. Unpredictable outcomes Physicians mentioned the lack of transparency and experience of arbitrariness the promotion process could entail. One physician relayed his experience: “I was told I had enough publications and was ready for promotion. When I didn’t get approved, I was very surprised. My mentor was also surprised.” When pointing to promoted physicians within his department, another physician noted, “It seemed like they got there despite a lack of training..” Perceived bias For clinicians, the process appeared so biased towards investigators that, as one confessed, “I felt it wasn’t worth the effort to even engage in the promotion process.” This was a NAH-wide issue, as a conference leader from another department elaborated, “Many of the physicians I met with were not interested in being promoted, saying things like ‘That’s a black box for me,’ or ‘I don’t want to go through the pain.’” Yet another physician described “navigating the labyrinth that is the UMS promotion system,” and noted there seemed to be “a behind-the-doors- bargaining” aspect to the process, calling the system “dysfunctional.” Among investigators, there were varying reports of how to “work the system.” While establishing oneself as independent was critical, there was an inherent conflict, as one investigator-track physician explained, “I have to be totally independent, which is increasingly unrealistic in terms of grants in the current economic environment, while at the same time the fastest way to move my science forward is to collaborate. I still collaborate with my former mentor, but this seems to be having a negative impact on me establishing myself independently.” Given that the promotions process was perceived as subjective and unpredictable, many expressed little interest in pursuing promotion. “Sure the money is a bit better, but it’s not worth it,” one faculty noted. A leadership physician noted, “For many, promotion is not a matter of financial goals, it’s about reputation.” (Exhibit 2 provides more information on promotion criteria by track.) Giving and Receiving Feedback Interviews also revealed that physicians had very divergent experiences in terms of giving and receiving feedback. Many younger physicians indicated they had no formal feedback or mentor relationship with a senior physician. Some reported they rarely got feedback on their performance, except in the heat of the moment when things were going poorly. Giving feedback was also challenging; one division head reported that rather than confront a difficult clinician about a conflict in style and operating room performance, she stopped scheduling him with senior physicians who were unhappy with his work. When he noted that he was not being scheduled he confronted the division head, and she was forced to give him the feedback she had hoped to avoid. One department chair summed the underlying cultural issue: “The medical world has traditionally not been very good at training people to interact in those kinds of ways. It has evolved to produce autonomous units.” A perceived bias towards investigators versus clinicians and educators also emerged from the interviews. Most acknowledged that scientific research had a built-in process for feedback; such feedback was far more likely to be ongoing, in both formal and informal ways. Additionally, the steps along the way for success as a researcher were much clearer than those for a clinician, as one physician noted, “You need to get a certain kind of grant, you need to generate results for a certain 411-018 Development and Promotion at North Atlantic Hospital 4 number of papers, and you need to get published.” Collaboration was also far easier for researchers he added, “as you are already in a lab, working on projects with other scientists, there is precedent for first, second, third authorship issues, and so on.” The flipside of this bias was the perceived marginalization of clinical work. As one clinical physician stated, “Success here has been defined by the time you’ve spent away from the patient.” Even in basic career guidance, both clinical and investigator track physicians acknowledged that that they received far more mentorship and guidance regarding their research activities than their clinical activities. A division chief noted, “Only a few clinicians have been recognized with promotion. There are physicians here who are nationally and internationally recognized as great clinicians—by their presence in the operating room, as mentors and so on—but until very recently, there has been no mechanism to promote them.” Harris and Cook knew giving and receiving feedback had to occur throughout the year, in both formal and informal ways, in order to be effective. Harris was not sure her department offered adequate opportunities and processes for such feedback to occur. Different physicians received and required different coaching, mentoring and feedback; aside from personal differences, their respective tracks—clinician, educator or investigator—also meant respective physicians from these tracks needed and received very different kinds of feedback throughout the year. Additionally, different tracks had very different criteria against which performance was measured. Investigators For investigators, the research environment provided many natural opportunities for mentor relationships, through their lab directors, co-authors or other collaborators. As several research-based leadership physicians noted, there were regular opportunities for giving and receiving feedback in an investigator’s work life, including “bench” conversations, weekly lab meetings, grant proposal processes and conference presentations. In fact, several research leadership physicians saw no need for an additional conference initiative. Some even resented the possibility of additional oversight, as one tenured researcher said, “I bring in grant money, I pay for my employees and I work with them to help them succeed.” Clinicians In general, clinicians reported fewer opportunities for structured feedback. “They get very little exposure to practice-level feedback, in terms of guidance for their careers, and promotion questions are very ambiguous,” one leadership physician noted. “What should be the frequency of conference sessions for them? Should these physicians be more distributed among their division head or by clinical practice?” Educators With the new track to recognize educators, Harris and Cook were still uncertain about what kinds of feedback and mentorship challenges this group faced. Additionally, feedback sessions would inevitably involve difficult conversations, and given the natural tendency to avoid such conversations, most leadership physicians acknowledged the great care that needed to be taken in delivering effective feedback. Several leadership physicians had an anecdote from their own past illustrating how negative or ineffectual feedback had played a role in their own career experiences, including being dissuaded from pursuing a goal, indicating that the mentor or career conference leader was not attuned to their specific needs or experience, to being convinced that career conferences were a waste of time, and to be avoided. Most NAH leadership physicians interviewed felt that training on how to give feedback was critical, however, this also raised challenges. As one leadership physician explained, “If you are selected to lead conferences and give feedback in a formal forum, there is an implicit assumption that you have been selected because of your leadership position and your inherent leadership abilities. This makes you exactly not susceptible to training in some cases.” Development and Promotion at North Atlantic Hospital 411-018 5 Work/Life Balance Some leadership physicians felt topics related to work/life balance—which might range from such topics as divorce, a new baby, illness, or caring for an aging parent—remained taboo and should not be discussed in a career conference setting. “That’s none of my business,” one conference leader said, “and I won’t bring it up unless the physician wants to discuss it, but even then it seems outside the realm of career conferences.” Some physician felt similarly; as one said, “Those things are private, and I do not consider them part of my work challenges.” However, other leadership physicians felt strongly they could only guide physicians if they were aware of all the challenges they may face. This was especially true when it came to performance that did not meet expectations, or problematic behavior. “I’ve found that I can better assess my physician when I am aware of all the stresses they may face in their day-to-day lives,” one department chief noted. For some physicians, the ability to achieve their work goals was integrally tied to the support and resources they got to help them protect their time, or have their life challenges taken into consideration in an assessment of their work goals. Additionally, challenges were inherent to the differences in career goals and work/life balance expectations between generations. Culture In terms of the hospital’s and the department’s cultural support for giving and receiving feedback, and mentor relationships in general, several physicians noted that “who you knew” mattered (whether they acted as a formal mentor or not), especially in terms of the “power” that person was perceived to have. “‘Say’ matters here,” one young physician explained. “If you want to get anywhere, you have to have someone to advocate for you.” But several physicians reported a more general malaise underlying the department in regards to development and promotion. “I feel pretty out on my own,” a young physician acknowledged. “The system is unclear to me, and no one seems to care that much about how I do. I was a top fellow in my resident’s program, and had all kinds of resources to support my research. But now that I’m here, there’s no support, or even a sense that my success is important to the institution.” Another young physician concurred, “It’s like you made it to the top by getting a job here. But in some respect, once you are here, that works against you because everyone more senior than you is so focused on themselves and their careers, there’s no one to guide you as you try to make your way.” Career Conference Program Practices at NAH Harris and Cook informally surveyed the leadership of their peer departments to learn what each provided in the way of professional development, and where applicable, what kinds of career conference programs they ran. Some departments had successful career conference programs formalized as annual meetings to assess past performance and set goals for the future. Most felt that these programs played an important role in departmental staff development—including promotion— and in communicating the department’s mission, vision, culture and expectations. Success of these programs varied, however, depending on department size, resources, administration support and commitment from the department’s senior leadership. Due to recent funding constraints some had been forced to morph into “group” conference sessions or were held at less frequent intervals. Several leadership physicians claimed their conference programs were an important tool in the management and performance of their staff. The conferences offered important opportunities to set expectations for physician performance and citizenship, as well as for department norms and values. One department chair explained: 411-018 Development and Promotion at North Atlantic Hospital 6 The conferences serve several purposes. Chief is to learn what the physician has been doing, and to get fairly granular information about what areas they have been involved in, what areas they’ve made progress in—clinically, academically, teaching, discovery, and papers—what citizenship activities they’ve been involved in, and what committees they have served on, what has been the person’s role in outside institutions. Overall what progress has been made? This gives me—or any evaluator—a handle on ongoing trajectory of the person, helping me determine where do they want to go, and specifically what their academic promotion goals are. It also provides me the opportunity to let people know what’s expected of them. Basically it enables me to create congruence. But more importantly, the conferences are a very important tool for getting buy-in across the department. My conferences include some discussion of compensation. Not long after the conferences are completed I present the department’s financial report at a department-wide meeting. There is complete transparency about our P&L and they can see for themselves the direct impact our private discussions about compensation have on the department’s budget. Interviews with other department leadership revealed that conference programs could communicate important cultural and management values to department faculty. One division chief recalled, “I think our career conference initiative was one of the best things that happened in terms of community in our division at the time. The message was ‘We care about the physician staff.’” Most leadership noted that the language and behavior used in framing the conference meetings as well as the actual language on the conference forms should be carefully considered. Another division chief explained his approach at length: I first made initial contact with each of the physicians I would meet in conference; I knew none of them in advance. I let them know our meeting would be informal, that I wanted to get something on paper from them in advance. I went to them. This was a key factor. I met them in their work place, sat and talked with them on their turf. Not only did this help their level of comfort in terms of environment, it meant our “hour” discussion was really an hour. They felt an immediate level of trust in me too, as they could see I took their time seriously, and respected the demands their schedules made on them. Conference Logistics NAH department chairs diverged on who should lead conferences. Where possible—i.e. when the department was small enough—many felt it was most effective for the department chair to lead them, and even in one of NAH’s larger departments, the chief reported meeting with every physician, despite the fact that he or she also had his or her sub-division chiefs meet with their assigned physician. “The department chief has the most credibility and power in the physician’s constellation of work relationships,” he noted. “He or she is in the best position to provide the resources a physician needs to achieve their goals. The perception is that the department chair is the ultimate arbiter, and in the end is the one that can make a difference.” Physicians reported a perception that internal politics could play a critical role. “Who you know matters,” one physician noted. “Having someone powerful on your side is very important.” Department chairs and division chiefs pointed to the inherent conflict of the time commitment required to effectively lead conferences versus the attention they needed to pay to their own careers. “Leading conferences, and mentoring activities in general, are not recognized or rewarded in our world,” one explained. “And they take time away from the things I should be doing to further my own career.” This raised the question of how many physicians a conference leader could realistically Development and Promotion at North Atlantic Hospital 411-018 7 manage in a conference program. One conference leader in another department noted she could manage approximately 15 physicians a year; more if she had an administrative resource to provide logistics and scheduling support. Once NAH mandated career conferences, preparation for the meetings became fairly uniform. A standard form was drawn up and physicians filled it in prior to their meetings, answering questions probing their achievement across the prior year and goals for the upcoming year. One division chief was quick to point out that the form’s questions needed to reflect the values of the department; “The questions tell people what is important,” she said. “The conferences are where the rubber meets the road.” Finally, conferences were only one aspect of most departments’ development efforts, especially with regard to helping physicians in the promotion process. Additional resources such as CV writing workshops, journal writing tips, practice sessions for presentations of papers, promotion-related workshops and peer gatherings supplemented the guidance offered through the conferences. Since joining NAH, Harris provided additional one-on-one counseling, and together with Dr. Cook, had launched a mentorship pilot program. Conference Practices across NAH Departments Along with performance management and career guidance, the career conferences offered the opportunity to align a department’s chief and its physicians. Most senior leadership physicians believed that giving feedback or providing guidance was “already something they did” in their day- to-day jobs, whether as division, or sub-division, chiefs, or as directors of a satellite clinic or service. To be effective as conference leaders, department chairs and division chiefs mentioned the need for resources to support managing the conference process on an ongoing basis. Some indicated they had a dedicated full- or part-time administrator to coordinate the conference process, especially for departments with a very large faculty of physicians. Other innovations to help ease the burden of time on the conference leaders included making the forms to be filled in prior to the meetings web- based, this also allowed for a more sophisticated and thorough analysis of the data polled in real time and over time, which could feed back to the process in terms or measuring certain critical dimensions such as collegiality, or commitment to the institution, or job satisfaction; one conference leader commented that an increase on some of these dimensions “really motivates our physicians.” There was some debate over how often conferences should be held. Harris and Cook found that most NAH department chairs held annual meetings. Some noted that conferences could be held a bit more frequently (perhaps every nine months). Some department chairs were not wed to an annual conference schedule, and felt conferences could be held every 18 months or every two years even, without any adverse impact. Their perspective however seemed to rise from whether the time between conferences was adequate to achieve the goals set in the conference. Hand-in-hand with the question of how often to hold conferences, both conference leaders and physicians who attended conferences reported that who led the conference mattered as well. Most conference leaders acknowledged that mentoring relationships played an important role in feedback and conferences. “The process of feedback is continuous and ongoing—some of the interactions will be informal, some more formal,” one noted. Another explained, “It does no good to only give feedback in a once-a-year meeting. There is no context for it. Good mentoring and career guidance requires a relationship of trust be established between the physician and their mentor or supervisor.” “There is no point in doing an annual conference if that is the only interaction the physician has in terms of feedback,” another conference leader said. 411-018 Development and Promotion at North Atlantic Hospital 8 Physicians also felt that feedback had to be an ongoing and regular process. One physician noted, “Getting guidance from someone senior in my department, once a year, without any sort of relationship context for that guidance aside from the fact that they are my senior, can be very confusing and at times alienating.” Several physicians mentioned that an open-door policy amongst conference leaders, be the department chairs or division chiefs or senior physicians within their department, would improve chances for regular, informal feedback. Some senior physicians were identified as more approachable, making it easier to seek out feedback. Mentoring, however, despite being an important part of citizenship, was notoriously time consuming and difficult to reward. All agreed that effective mentoring required a one-to-one relationship but acknowledged it was difficult to make the time necessary to develop ongoing effective mentoring relationships. Some NAH departments had formal mentoring programs, where incoming or newly hired physicians were assigned to a mentor for their first year, and then subsequently had the opportunity to shift to another, perhaps more suitable mentor after they became familiar with their department’s senior physicians. “Assigning mentors for new physicians makes sense,” one senior DA physician reported, “because you need to know the programs well in order to pick intelligently, and you don’t have this knowledge when you first come in.” In addition, assigning a more senior physician to a new hire might be counter-productive; as one physician noted, “A recent hire can help someone new transition more effectively than someone hired 20 years ago.” Some suggested the term “mentor” might be inappropriate at this early stage in their tenure in the department, and suggested maybe “advisor” was a better term for the relationship. Physicians noted that different mentors would be required to give guidance on research versus clinical work. In other departments where there was no formal mentoring program some physicians reported proactively selecting their own mentor, either for specific research activities, or more generally as professional role models. Physicians noted that senior physicians who acted as mentors to only one physician risked being perceived as playing favorites. Of the physicians interviewed, women disproportionately reported seeking out mentors over their male colleagues (the mentor chosen might be either female or male). One physician noted, “I had a couple male peers come up and ask me ‘How did you get Dr. Smith to agree to be your mentor and let you work with her?’ To which I replied ‘I just asked her.’ So then I coached them on how to select their own mentors.” Some physicians reported that the best way to learn how to develop themselves was through the observation and role-modeling of their informal mentors. Almost all physicians described the need for a mentor to advocate for their mentee, lobby to get them resources, and help protect their time to achieve their promotion/career goals. Good mentors were perceived to be invested in their mentees, and required building a relationship over time. “A mentor needs to be invested in you,” a physician noted, “and that doesn’t happen with one meeting a year, or even two. You need a closer relationship.” Conference Practices Through their interviews, Harris and Cook amassed a range of conference practices. They organized these into three phases, pre-conference work, the conference meeting itself, and post- conference actions. Pre-Work In those NAH departments that already held them, annual conferences were typically held from April–June, or June–October, depending on the department’s schedule (often this schedule was tied to when compensation and bonuses were set). Each conference was scheduled to last about one hour. Development and Promotion at North Atlantic Hospital 411-018 9 For a division chief with more than 25 physicians, this was a significant amount of time, not to mention the time required to schedule the meetings. Many of the leadership physicians started their conference process at least a month in advance, planning for time to prepare for each meeting by reviewing forms filled out in advance and to set out their goals or cover specifics from the year. Physician then submitted the filled-in form and their updated CV. This preparation time also involved gathering feedback from sub-division chiefs or other supervisors, physician peers, nurses and residents, and in some instances, even patients. Forms Conference leaders relied on some version of a paper form sent to the physician in advance of the conferences. The form typically asked some variation of questions such as the following: “What have you achieved in the past year?” “What are your goals for the upcoming year?” and “What support will you need to achieve your goals?” (Exhibit 3 provides an example of the form.) The forms ensured conference leaders “got the information they needed,” as one division chief said, as well as helped the physicians focus in on what had been accomplished over the previous year. As one leadership physician noted, “For some there is an Aha! moment—they see they haven’t done anything.” More specifically, he explained, the forms helped provide a prescribed format to the conferences and gave consistency to the discussion—for both the physician’s immediate conference leader, or in some of the larger departments, when sub-division chiefs reported into their chiefs and the chief met individually with each physician subsequent to their more in-depth meeting with a sub- division chief. A signature line to be signed in-person at the end of the meeting also helped reinforce a mutual understanding of what the meeting formally represented. The Conference Itself Many conference leaders agreed that starting the conversation tended to be the most awkward moment, and most suggested a soft opening worked best, soliciting the physician’s own assessment of their year to get the ball rolling. One division chief spelled out her recipe: “I ask: What are the three things you want to accomplish in the upcoming year, and what are you most proud of doing in the past year?” Conference leaders were unanimous in stating that it was important to stay on track during the conference, and most suggested using the form to, as one described, “convert what could turn into drift into focus.” However, more than one conference leader noted that the conference was often the only outlet some physician had ever had where someone asked them, “How are you doing? Tell me about yourself and what your passions are.” As this conference leader acknowledged, “This might be the only question asked in the entire meeting, depending on how long it had been since they’d talked to someone they might refer to as a mentor, that question could often take up a good portion of the time allotted.” Conference leaders stressed the importance of ending the conference with an action plan. Typically this was focused on short term goals, especially in terms of achieving promotion, such as producing a certain number of publications, getting nominated to a committee, presenting research at outside conferences, and so on. Most conference leaders reported they took notes during the meeting, and wrote these up in a formal way to include in the physician’s file; many shared the notes with the physician in question prior to filing them to ensure agreement over what was discussed. Conference conversations could range across a spectrum of topics, according to conference leader. On the one end, some reported, was the “don’t rock my boat” conversation. One conference leader explained: In these conversations there tends to be a focus on “Thank you, thank you, I’ve had a great year, let’s all agree and be done with this conversation.” They’ve made it through another year, 411-018 Development and Promotion at North Atlantic Hospital 10 and they don’t really want you to rock their boat. They want a consensus-type conversation— you both are in agreement about the progress they’ve made, they seem on track and are going in the right direction. At the other end of the spectrum, however, conference leaders acknowledged, were the conversations that “no matter what, were never going to be happy ones,” as one conference leader said. “The physician is unhappy for a number of reasons, only some of which may have to do with their work life.” In such instances, one chief‘s strategy was to convince the physician “that they’re part of a team.” The chief explained, “The conference is an opportunity for you to help them see that the environment they are working in allows them to do the work they do and pursue their interests. At the same time, the conference is an opportunity to help this particular physician see how their performance may not be meeting expectations or department standards.” Conference leaders agreed that effective feedback had to be timely and specific, presented in a positive way, with actionable items to work towards improvement. “I always try to start with the positive,” one conference leader noted. Conference leaders were unanimous on what constituted effective feedback. One summed it succinctly: “Start with positive feedback. Determine how to frame negative feedback. Think about ways to give feedback that is not hurtful or counterproductive. Call out specific goals and objectives. And learn how to have conversations about career aspirations with people at different stages of their career.” Conference leaders reported that preparation for the feedback session was also important, but keeping the conversation open worked too. As one conference leader said, “Let them describe their experience, typically they will then give you the opening to probe on specific matters you want to discuss.” Some suggested that the end of the conference could include a summary of agreed-upon goals and areas to focus on; as one conference leader said “I close out with a list of next steps for the physician and for me to follow up on.” On the physician end, receiving feedback in the conference could vary in terms of effectiveness. One investigator track physician recalled: It was very discouraging—after years on my research project—to have Dr. White say ‘Well you should really go with a different project, maybe you should research into [X] or [Y]. It was like they had no appreciation for the years of work I had already put into my project, they were just trying to advise me on how to have a project that was fundable. I understood they were trying to help, but it just took the wind out of my sails. Physicians were unanimous about honesty being the single most important aspect of any feedback. Additionally, listening and showing responsiveness were identified as important traits to exhibit during the feedback exchange. When dealing with concerns, one physician noted, “don’t pooh-pooh my concern, or brush it off to try to make me feel better. Give me recognition that there is something to be concerned about.” There was some discrepancy in opinion about how much the conference should touch on personal matters impacting the physician’s work life. Conference leaders were divided on this matter. Some felt it was integral to the conversation to learn what they could about all the elements impacting the physician’s attempts to achieve their goals; others felt it was not appropriate to broach these more personal topics in the conference. Physicians receiving feedback were equally split. Some welcomed the opportunity to discuss all the aspects impacting their work lives; others were adamant that “these are not topics relevant to a discussion about my work life.” Development and Promotion at North Atlantic Hospital 411-018 11 Post-Conference Follow-Up After the conference, many conference leaders mentioned that it was important to follow-up on specifics mentioned. These could be small items such as directing the physician to a resource or possible collaborator for a project. One conference leader kept a “tickler file” keeping track of the things she wanted to follow up on within a month of the conference meeting. Most followed up more generally within a set time frame. As one conference leader said, “After six months a ‘teaser’ email was sent out from the administrator of the conference program along the lines of ‘It’s been four [or six] months, just checking in.’” Harris recalled a conversation with another division chief. The division chief acknowledged the challenge in getting some physicians interested in the process. As the division chief explained, “This is a process that rolls downhill. You have to get your division chiefs and other senior physicians involved, then he or she goes back and hopefully carries their personal involvement through to their teams.” He continued: The secret is, “You’ve got to care about people, and care about product.” What worked best included ideas and suggestions that I felt weren’t that profound but were perceived as such by the physician, including reflections on my part—given my 50-year career in medicine. And doing most of the work to run the conference and follow up after for the physician. What didn’t work was when I failed to make explicit what these sessions were about. Physicians then felt pressured to come into a meeting, with no idea what it was about. Conclusion The hospital’s mandate for career conferences was very broad, and each department had the flexibility to develop, or augment existing, programs to best suit their faculty’s needs. Harris knew designing a uniform career conference program across the diverse DA physicians would prove challenging. Several prior unsuccessful career conference efforts meant her department was skeptical of a new initiative. Some senior physicians (division chiefs and research lab heads, for example) claimed to hold somewhat regular meetings with their teams to discuss performance evaluation and career development, yet an informal survey of these teams revealed they did not know these meetings were supposed to be about their career development. Feedback sessions, if they happened, were spotty. Others claimed that they did not have a sense that the senior physicians cared about their development needs. Still others expressed a lack of awareness that these conversations were aimed at their performance evaluation and career development. To address the department’s promotion challenges specifically, Harris and Cook identified two primary areas on which the career conference initiative should focus: development of individual faculty goals for the upcoming year and long-term career planning. They had yet to determine who should be conference leaders: Harris herself (the department chair), division chiefs and/or other senior physicians and principal investigators? Several additional key questions remained, however. Would the meetings be uniform across all physicians? Once conference leaders were selected, how should they be paired with physicians? Should the conference discussions focus solely on physician development, or should they also consider issues of general performance and compensation? How would the department recognize conference leaders for their time and investment? The design of the career conference program had many details to consider, but Harris knew that it offered the opportunity to make a broad cultural statement about her department’s commitment to its physician’s professional development. Harris and Cook turned back to their notes. 411-018 -12- Exhibit 1 Select DA Staff Satisfaction Survey Results Question Disagree Unsure Agree Does Not Apply Response Count I understand the UMS CV format and guidelines 7 19 65 1 92 I understand the UMS promotion criteria as it pertains to my Area of Expertise 12 20 58 1 91 UMS promotion is important to me 10 15 61 6 92 UMS promotion is based on merit 17 20 51 4 92 I have a good idea of how UMS promotion decisions are made 25 31 32 2 91 I believe that my department values UMS promotion 8 14 67 3 92 My department values collaboration and teamwork 14 20 55 0 89 I get the support I need from my department to achieve my career goals 29 25 36 0 90 I feel proud to be part of the DA department 9 15 50 0 90 I feel value at work 25 15 50 0 90 My peers are my best source of information about careers at NAH 25 23 39 3 90 My department helps me learn and grow 26 23 37 1 87 My department makes me feel a part of the team 29 18 41 1 89 My department assess performance in a fair and equitable manner 27 37 23 0 87 My department rewards and recognizes good performance 30 26 31 0 87 My department holds faculty accountable for poor performance 26 42 18 0 86 I welcome the opportunity to discuss my performance over the past 12 months 5 9 71 1 86 I welcome the opportunity to discuss my progress towards my goals on an annual basis 6 8 72 1 87 I find it useful to set goals for the upcoming year 5 13 67 2 87 I find it useful to set goals for the upcoming year in consultation with a mentor 13 18 49 5 85 It is important that I receive one-on-one feedback on my potential for promotion 8 16 55 6 85 I understand the expectations for my job 7 9 70 1 87 I have been provided a written copy of my job 57 13 11 5 86 My performance is being evaluated regularly 21 36 29 1 87 I understand the criteria by which my performance is being evaluated 34 32 20 1 87 I know that it takes to succeed in my department 27 29 34 1 87 In the conference, I expect to receive specific suggestions for how to proceed on track for my UMS promotion 22 4 65 7 78 In the conference, I expect to receive feedback on my past year’s performance 2 5 69 2 78 In the conference, I would welcome the opportunity to discuss work/life balance questions 12 18 46 3 79 In the conference, I expect to be able to discuss my compensation 3 7 64 4 78 In the conference, I expect to speak candidly about my work experience 4 3 68 3 78 The career conference will provide an opportunity for my department to recognize 8 14 54 3 79 411-018 -13- Question Disagree Unsure Agree Does Not Apply Response Count my achievements In the conference, I expect to be told I am proceeding on track for my career goals 4 20 48 6 78 On the whole, I am satisfied with my job 20 15 50 0 85 On the whole my organization helps me to meet my need to feel I “belong” 26 18 39 2 85 On the whole, I am satisfied with the leaders in my work environment 53 17 36 0 85 On the whole, I am satisfied that my views and participation are heard and valued 29 17 38 0 84 On the whole, I am satisfied with my ability to maintain a reasonable balance between family life and work life 22 10 52 0 84 On the whole, my organization helps me to meet my needs (e.g., money, status, recognitions, etc.) 23 23 39 0 85 I feel proud to be part of my organization 11 14 59 1 85 I feel loyal to this organization 10 8 66 1 85 I feel energized at work 16 19 50 0 85 My organization inspires me 27 17 41 0 85 I feel engaged at work 8 4 73 0 85 I would seriously consider an offer from another organization if I received one tomorrow 15 22 44 4 85 I intend to make an effort to leave the organization in the near future 15 22 44 4 85 I am actively looking to find another job 52 16 13 3 84 Question Yes No Response Count I have a mentor 41.6% 58.4% 89 I have a mentor in my department 37.9% 62.1% 87 I would like a mentor 54.1% 45.9% 74 Are you aware of the department’s faculty development resources? --CV workshop 89.5% 77 -- DA Promotions Committee 61.6% 53 -- DA mentorship program 39.5% 34 --Administrative support for CV preparation 52.3% 45 --Administrative support for promotion 33.7% 29 --One-on-one counseling/guidance 26.7% 23 In describing my optimal mentor, he/she would have the following qualities (please check all that apply): 411-018 -14- Question Yes No Response Count --Someone who can provide access to professional and personal resources 79.8% 67 --Someone who can provide broader perspective of career potential 89.3% 75 --Someone who can provide advice on how to effectively spend non-clinical time 48.8% 41 --Someone who can help me develop a roadmap to get where I want to go 66.7% 56 --Someone who can help me define a professional ceiling/limit 33.3% 28 --Someone who can help me navigate the UMS promotion process 61.9% 52 --Someone who can provide insights to achieve work/life balance 40.5% 34 --Someone who can help me fine-tune my leadership skills 46.4% 39 --Someone who can help me learn how to be a mentor 44.0% 37 --Other 2.4% 2 Someone on my department is interested in my career development --Chair 52.3% 34 --Division Chief 4.6% 3 --Other 24.6% 16 Someone in my department is available to discuss career development goals --Chair 40.9% 27 --Division Chief 9.1% 6 --Other 24.2% 16 It is important that I receive one-on-one feedback on my performance (please select all that apply): --As an investigator 47.3% 35 --As a clinician 74.3% 55 --As an educator 68.9% 51 --As an administrator 40.5% 30 --As an academic 55.4% 41 My last conference occurred: --Within the last six months 11.8% 10 --Within the last twelve months 14.1% 31 --Longer than twelve months ago 36.5% 31 I have not had a career conference 37.6% 32 The best person to lead my career conference is: --Chair 59.5% 47 --Division Chief 12.7% 10 411-018 -15- Question Yes No Response Count --Principal Investigator 1.3% 1 --Mentor 16.5% 13 --Other 10.1% 8 I expect to receive specific suggestions for improvement of my performance (please select all that apply): --As an investigator 49.3% 37 --As a clinician 64.0% 48 --As an educator 65.3% 49 --As an administrator 38.7% 29 --As an academic 52.0% 39 I welcome a follow-up from my career conference leader to check on my progress on the items we discussed in the conference: --weekly 0.0% 0 --monthly 6.3% 4 --quarterly 93.8% 60 Source: Company documents. 411-018 Development and Promotion at North Atlantic Hospital 16 Exhibit 2 UMS Promotion Tracks and Criteria for Promotion by Level Investigation Investigators devote most of their efforts to conducting research. Investigation may include basic, translational, and clinical research, or research in the social sciences, ethics, health economics or related fields. The level of expertise and extent of recognition varies between Assistant Professors, Associate Professors and Professors. The type of research conducted also varies among the three levels. A candidate for an Assistant Professorship must demonstrate scholarship through publications either as the first author or as part of a collaborative research team. The Assistant Professor must conduct basic research, clinical research and/or laboratory research and have a clearly defined role within a collaborative research team. Often the Assistant Professor will have invitations to speak in the local community. An Associate Professor must have a proven record of independent research (including independent funding ) a national reputation and be considered a major contributor within the field.,. The Associate Professor must boast a contribution of new investigative methods or technologies and also publish original research that advances the field of study as a senior author. A Professor has a strong national or international reputation as a top researcher who has made groundbreaking contributions to the field, and has published high-impact research. A Professor has received invitations to speak nationally and internationally, has served as an editor of a scientific journal, plays a leadership role in scientific societies and has published extensively in the field. Clinical Expertise Physicians who are considered to be clinical experts have been deemed innovators in regards to diagnostic, treatment and technological applications in the delivery of patient care. Aspiring Assistant Professors, Associate Professors and Professors must demonstrate clinical expertise through scholarship and a clear demonstration of the impact that their contributions have had on the changing face of clinical care. . An Assistant Professor should teach in the clinical field and must have first author scholarship, in addition to a strong local reputation as an expert and invitations to speak locally or regionally on their specialty. An Associate Professor in the clinical field must have a strong regional or national reputation and demonstrates innovation with respect to diagnosis, treatment or disease prevention. Associate Professors typically take on leadership roles in regional and national societies, and have influenced clinical practice beyond their own institutions. In addition, they’ve contributed substantially to the peer review literature as senior authors and have been publically recognized by their peers (via national awards) for their contributions. Professors have been recognized at the national and international stage for their accomplishments, have influenced clinical practice and have played a role in defining a new clinical arena. Professors have often served as expert consultants on issues related to their area of clinical expertise, and have had leadership roles in professional organizations in their clinical expertise. Educational Leadership This area of expertise applies to candidates who spend the majority of their time on educational pursuits and work primarily in academia. Teaching students, residents, clinical and research fellows, mentoring, and carrying out the necessary administrative roles all fall within the realm of Educational Leadership. Candidates for any level of professorship must demonstrate scholarship through the publication of original research, reviews, chapters, or other educational materials. Similar to the areas of Investigation and Clinical Expertise, Assistant Professors in Educational Leadership have demonstrated scholarship and hold a strong local reputation in the field of Education Curriculum Development. Assistant Professors have also served as peer reviewers, have contributed to local professional organizations and have awards for teaching and mentoring. Associate Professors have strong regional reputations and have demonstrated expertise through publications related to education. A Professor must hold national or international acclaim and be influential in the lives of many trainees. They have served as authors or editors of textbooks devoted to education and have developed educational methods or materials adopted nationally. Source: Sample promotion criteria. Development and Promotion at North Atlantic Hospital 411-018 17 Exhibit 3 Sample Career Conference Form (ACCS Standard Form) ANNUAL CAREER CONFERENCE for NAH FACULTY Faculty member should fill out this form prior to meeting with the Chief or Division Chief. The completed form and an updated C.V. should be brought to the meeting. Date of Conference: Name: Degree(s): Hospital Dept: Division/Lab: UMS Title: Hospital Title: Preferred contact information (Office/lab phone; email; mailing address) 1) Please rank the following activities according to your present commitment (1 – most, 5 – least). Patient Care Teaching Research Admin/Committee Work Other 2) a) What were your 2-3 most important goals for last year? b) List your 2-3 most significant accomplishments for last year. 3) Please attach your CV with these sections highlighted: Current activities in the following areas- ADMINISTRATIVE - Administrative title - Committees (NAH and External) OTHER PROFESSIONAL POSITIONS - Study sections: NIH or other peer reviewed groups - Positions in professional societies RESEARCH - Current grant support - Current research activities - Inventions - Patents applied for - Patents issued 411-018 Development and Promotion at North Atlantic Hospital 18 TEACHING - Formal presentations within NAH - Lectures/presentations: local, national, international - UMS courses - Clinical Teaching with residents, fellows, and medical students - Other MENTORING/ADVISING OF OTHERS - Names and Current Positions CLINICAL - Procedural (case volume) - Inpatient Consultative - Inpatient/Direct Responsibility - Outpatient Responsibility - Other PUBLICATIONS (highlight the previous year only) 4) Academic career aspirations: Which of the following promotion criteria do you think you meet? Clinician/Teacher Investigator I don’t know 5) Do you understand the UMS promotion criteria for advancement in your career trajectory specified above? Yes No, please explain Are we providing you the resources to succeed in your job? 6) Are there any activities in which you wish to spend - More time: specify Less Time: specify 7) List your current mentors, if any, and how effectiveness could be improved. Name: Comments: Name: Comments: Would you like help in identifying a mentor? Yes No 8) List those you have mentored, if any. Name: Comments: Name: Comments: Development and Promotion at North Atlantic Hospital 411-018 19 9) List your 2-3 goals for the upcoming year. ________________________________________________________________________________ At the conference, the Chief or Division Chief should fill out this portion of the form with faculty member. Future Career Advancement will require: 1) 2) 3) 4) Future support needed in the following area(s): Additional Training: Re-allocation of time and effort to teaching, clinical, scholarship and service: Resources: In addition, I have provided specific counsel regarding: __________________________________________________________________________ Both the faculty member and the Chief/Chief Designee should sign and date below. Signed: _____________________________________ _______________ Department Chair or Designee Date _____________________________________ _______________ Faculty Member Date Source: Company documents.