So now we're going to move on to talks on governance and team member attitudes, and we're going to welcome Dr. John Martin to the floor here. The eminent Dr. Martin is a world famous gastroenterologist who began his career at my institution before ultimately winding up at Mayo Clinic in Rochester, Minnesota, where he loves to drink tea. In addition to his clinical practice, Dr. Martin's interest center on endoscopy unit operations and efficiency. He is well known in the world on these efforts as well as his clinical research. He has several technological innovations and endoscopy under his belt. He has served on the ASGE governing board and currently serves on the ASGE practice operations committee. John, welcome to our course. Gerard, thank you so much for that kind, warm and very personal welcome. Deeply appreciate this privilege to join you and Nisa and Eden and the entire practice event staff from ASGE. This is a great course, and I am so pleased to be a part of your team. So thank you so much. My talk follows Dr. Eisenberg's talk and Dr. Kabilian's talk for a very good reason. And that is that you heard about the importance of providing care on a team basis, and what it takes to lead a team effectively. And to do those things, we need to actually build and cultivate a team to work together and a team to lead. And that is the nature of my talk, which indeed is building and cultivating your team, recruitment, retention, termination, and outsourcing. So here we go. I have no financial relationships with commercial support to disclose. So how do we build and cultivate our team? It's a big undertaking. It includes recruitment, retention, termination, and potentially outsourcing. And all of these things must be done according to a unified plan with a forward thinking vision in mind. So what do build, cultivate, and team actually mean? It's good to really sit down and think about the meaning of each one of these words, so that we don't just gloss over. So build means to develop according to a systemic or systematic plan. So we're not just putting something together by slapping it together. We're looking at building a system. We're looking at building an organ. It's not just a collection of cells, but it's a collection of cells working together. So there's a definite process, and there's a particular base to this. So for example, built the organization from the ground up. Or it can mean to make stronger or more intense. And what about to cultivate? What does that mean? It means to foster the growth of or to improve by labor, care, study, to refine, to try to develop and improve something. So important also to remember that cultivate as a word shares the root word with culture. So culture and cultivate come from the same root word. And so when we think about cultivating, it's important to think about the word culture and the fact that culture can propel us forward if we are truly working as a culture and a team. But if we hold too strongly to the culture that works today, it can actually hold us back. So we need a culture that not only addresses today, but can help us to build for a successful tomorrow. And what about team? A team is a group of people who act together in order to achieve something. A group of people working toward a common goal and or a common purpose. So rather than cultivate, we need to recruit. We need to bring people into our team. How do we build the team? We search for talent and skill set, but we do this in an organized fashion by thinking forward to tomorrow, not just to today's needs. And the plan that we use for recruitment needs to be integrated. So no recruitment of even a solitary team member should be a standalone recruitment. We're not just plugging a hole. We're not filling a void. We're thinking about recruiting a thread to weave into the fabric of our team to make that fabric stronger and more durable and more likely to be a useful fabric for tomorrow and beyond. We're also looking for that thread to really fit into that fabric to enhance its appearance, enhance its durability and its utility. So we need somebody who not only is going to be capable of fulfilling the clinical need, for example, but also someone who's going to fit into the culture of the team and enrich it. That's a successful recruitment. So putting growth into perspective of the team for today and tomorrow. Recruiting new physicians and APPs, the actual providers, can bring volume into the practice, the center, and the hospital and the health system. You can also bring new skills, clinical expertise, business proficiency and research talent to your team. Recruiting new nurses and tech staff can expand your clinical skill set and capabilities, increase your volume and throughput, augment efficiency and improve care quality and patient satisfaction. It's not only important though to bring in new talent, it's really important to successfully retain the exceptional talent that you already have on your team. This isn't automatic, doing what it takes to keep that valuable human resource, each and every team member that you value on your team. You've already successfully recruited these people. Put the effort and the resource into training them. You've developed them, and they've become a culture to your team. That is tremendous, tremendous effort. And that's effort that you don't want to waste by having that successfully recruited, trained, skilled, cultivated person who's part of your team culture, suddenly up and leave. You don't want to waste that effort by having to recruit someone to hope to fill that void just as successfully. How do you keep great people? You keep great people by providing opportunities for career and personal growth, achievement, life satisfaction, recognizing and supporting the importance of their lives outside of work, accommodating their legitimate needs when they arise, demonstrating appreciation for different talents, skills, and values that each member brings to the team uniquely, and by properly compensating each member of your team. These people are your practices biggest investment and greatest asset. What are the costs and opportunity costs of replacing a departing member of your practice? They're huge, not only in terms of resources, but also time. These are scarce resources, these human resources, and you're not going to be able to recruit right away. These short term negative impacts can be sustained by your practice through individuals departing your practice. Retention requires remaining competitive with other practices in terms not only of professional opportunity, but also compensation, business opportunities or buy in opportunities, educational and skill development, multiple elements of not only professional, but also personal satisfaction. For worse, sometimes cultivating your team includes termination, because not everyone necessarily fits into the culture, or they no longer are a good fit for the team. This may be not only with respect to their clinical productivity, but also their work skills, or their work quality, or their team values and integrity, or their ability to fit into the culture. Maybe they fit into yesterday's culture of your team, but not necessarily going forward. And sometimes, while there is a time to say hello, there is sometimes a time to say goodbye that isn't necessarily the time of retirement. What's important also is outsourcing, because you can't always meet the skills and talent needs of your team for tomorrow or even for today, just from your internal talent and skill pool, so you have to look externally. This allows you to add to your team without hiring directly into your practice. You can address temporary needs by outsourcing. This is a great opportunity to infuse external ideas because these outsourced individuals can bring ideas that you can incorporate, which they gleaned from earlier workstations. You may allow for hiring into your practice because someone who is outsourced into your practice temporarily, you might find to be an exceptionally great fit, and you may be able to successfully recruit that person as a permanent team member. By outsourcing, you can sometimes avoid the cost of benefits, and you can circumvent long-term commitments unless you ultimately decide you want to try to recruit that person permanently into your practice. Outsourcing, of course, comes with its own multiple potential challenges and limitations, which have to be taken into consideration. But remember that human resources are our most important and most valuable resources. They are our frontline, client-facing members. They are, at the same time, our most costly resource. They are also, however, our most remunerative resource. This is where your practice income comes from. This is your profit center. Because they are a scarce resource, it is effortful to recruit these people. Physicians and nurses are licensed. There are only a limited number of educated and trained physicians and nurses who are minted every year, and you have to compete for them. Remember that the demand for health care is high. It's unsaturated. It's essentially insatiable and only increasing. I think everybody saw the incredible jobs report that came from the federal government yesterday. Every one of those jobs that is added is someone who is now generating income, and many of those people have tremendous health care benefits, and they're going to be desirous of using them, and you are going to have to attempt to meet their access needs. To do that, you're going to have to compete for the scarce, licensed, professional resources that nurses and physicians represent. So what are the resources that are available for recruitment? Well, providers, obviously, from other practices that you can recruit. You can turn to professional colleagues, friends, or family. They might be able to clue you in as to who might be available to recruit. You can turn to medical organizations and societies, recruiters, recruitment events at professional society meetings, contact training programs, fellowship and nursing training directors, recruiters, recruitment firms that you can pay to do this work for you, and turn to advertisements or postings in medical journals, classifieds, social media, social recruiting, etc. Now, what can help to attract excellent partners and colleagues? Well, that kind of depends on your practice type and setting, but whatever setting you're in, you really need to put your best features forward, not only so that you're most successful at recruiting, but successful recruiting really means you're being happy and the recruit being happy, right? So it's really trying to find a situation where both people are going to be happy in a durable fashion. You do this by demonstrating the strength of your practice or referral base, showing how high your departmental and institutional rankings are, etc. Showing your opportunities to utilize specialized skills within your practices to the potential recruit, focused clinical expertise, and the ability to use that and the strengths that you have in key areas. You want to feature opportunities and practice opportunity in practice operations and innovation, leadership opportunities that might attract individuals who have an interest in those things, or perhaps the opportunities that you provide in ownership or a share and ancillary dreams. Your practice might have passive income opportunities that might be attractive to some recruits. These things can include potential to buy into an ASC or equity interest opportunities and some of these can even be possible in employed physician settings. There might be opportunities to participate in ancillary practice related businesses of various sorts. Leadership opportunities, research opportunities, the opportunities to be mentored by more senior providers. All features that might be attractive. So market your strengths, whatever they are, because your practice is unique and your practice is going to have strengths above those that competitive practices might have. Feature your financial performance success. The preference of third parties have for your particular practice, what your long term strategies of success might be. Better opportunities for career and personal growth, growth of the practice, career longevity, improved compensation and benefits, your compensation model, ancillary revenue streams, not only your practice strength but the strengths of the institution and system that you may be partnered with, what your academic affiliations are, your robust quality assurance program, your participation in benchmarking efforts. Put your best foot forward. Don't be shy, feel that your recruit deserves to know why your practice might be the best fit and opportunity for them. Emphasize other strengths like where you're geographically located. Not everybody wants to live in exactly the same place. They want to ski. They may want to fish. They may love being at the beach. Stress whatever opportunities you have. Every location has its own strengths and not everybody's looking for the same thing. Take advantage of what your strengths are. Offering long-term potential through life changes can be very attractive. Call coverage distribution and what's entailed in on-call responsibilities can have a lot to do with the quality of life outside the hospital. Opportunities to move within a practice or system can keep things fresh for decades in a long and successful career. Harmony in and collegiality of your entire team makes the workday a happy place and puts a smile on the face of any employee walking in every morning. And low provider and staff turnover. If that's what you feature, that's a huge success. That should be a talking point. For recruiting physicians and APPs, consider recruiting from area hospitals because these are physicians and providers for whom their personalities, their ability to fit in, skills, expertise may already be known to you. Or at least you can reach out to people who you know that can give a candid assessment of the qualities of your potential recruit. They may already have come through your hospital so you've seen how they work and how they interact with your team. They already know the system. They already know the way your hospital or your clinic operates. The market, the culture. They know referring physicians. They already have a reputation in the community. These people can be incredibly valuable to recruit because the unknowns are fewer. Try to determine ahead of time if there may be licensing, privileging or credentialing issues because getting a license these days can take a long time. If somebody already holds a license in your state, they can be recruited and up and running more quickly. Make sure that they start that license application right away if they're not already licensed. We have great resources from ASGE's website with respect to credentialing guidance. So go to those, they're free for you to access. Remember that being privileged includes not only the credentialing checks and all that's required for that but also demonstrated competence. So talk to people who know the practitioner that you're thinking about recruiting so that if there are chinks in the armor, you can figure that out ahead of time and definitely before the interview. And remember the interviews cost you time and money and due diligence is required before you and your team invest time and money into that interview process. And as Al Baker, one of my mentors used to always remind me it is easier to stay out of trouble than to try to get out of trouble later. Leverage your personal connections. If you're a part of a training program or no training programs, get on the phone or email or text the program director. That can be a great source of recruitment. We do that all the time. We have our own training program at multiple locations and we try hard to recruit our successful trainees because that is a known variable. We know what we're getting that way. That has advantages but also disadvantages because you can become an inbred group if you only recruit your own. But recruit your best if you can and then weave in others from outside for new ideas. There are targeted advertising resources that you can seek out, social recruiting, medical society and organization sites, publications and meetings. Engage all stakeholders when recruiting, not just providers or not just nursing staff but your administrative staff, your secretarial and support staff, research staff, HR, et cetera. They all have something valuable to provide in the recruitment process. And as with any decision-making and any team type of effort, everybody has a useful opinion to provide. And you wanna sort these out upfront, not deal with problems after the fact. Recruitment of staff, importantly depends on knowing your options for staffing positions, choosing the best staff mix. And Debbie Salls is gonna talk about some of the specifics here next. There is versatility versus cost-effectiveness on your staff mix. We'll talk more in the discussion about what the concept of a weighted FTE is because this is very important. You have a staffing plan in place, then go forward and recruit according to that plan. So what to emphasize is what does your practice provide that working in a hospital or an inpatient setting doesn't? Maybe you offer more interesting work or perhaps no calls or weekend or evening hours, a greater variety of shift durations or maybe no overtime or maybe people want overtime because of the income there. They want overtime and you have it available but that overtime isn't mandatory. Or maybe you offer better pay or better educational or traveling opportunities or even something that might seem mundane like childcare assistance or parking privileges, liberal leave opportunities. These things can be immensely valuable to a particular individual. And you wanna talk about these and put them on top of the table. And for techs, they can learn valuable skills because many of these people actually want to go to school. They wanna become nurses and maybe you'll offer them opportunities such as educational support or opportunities to be hired as a nurse after successfully graduating. The way we do it at Mayo Clinic where I work for nurses and techs is all of these things. We have a leadership model based on servant leadership like Dr. Kabilian talked about. Nurses have a seat at the table and a voice through their own department which is on an equal footing with the medical departments. Nurses can move about freely throughout the enterprise and selfishly, I mean, there are pros and cons to that. We lose people to other departments in GI all the time but it keeps nurses happy within our institution. And it also keeps us on our toes in GI because we know we have to compete with surgery and urology and psychiatry and every other department in the hospital that can successfully recruit the nursing staff. There is competitive total compensation provided. It's more than just the hourly compensation, right? And opportunities for professional growth and career progression throughout a successful professional career for our staff. Leverage your corporate partner if you have one, HR is going to have all sorts of expertise for staff recruitment and workplace matters throughout employment. Also leverage your corporate partner for marketing and physician recruitment because they have deep professional resources and deep pockets to help you fund a professional recruitment effort. Retention of physicians and providers is very, very important. We said earlier that it's really resource intensive to recruit providers. Much of what pertains to recruitment provides to retention. So it's important to retain the good people you've already recruited. Make everyone feel valued and uniquely contributory. Dr. Eisenberg underscored this. This is how you keep valuable people who are uniquely talented. Give everyone a real seat at the table. Listen, opportunities for growth and change without leaving the practice are important. Otherwise people who can grow are gonna leave to grow. They're gonna do that. So to retain them, you need to help them to grow within your group so that they don't have to leave to continue to grow. Give them an opportunity to add value to the practice, avoid burnout, keep on top of compensation and benefit trends. You need to compensate people for what they're worth. And the way that they are gonna measure their worth is what their value is outside their present practice, not what their value is within their current practice. You need to keep up on that. Emphasize harmony in the entire team, accommodate personal needs like we said, and practice the servant leadership. Remember the pyramid that Dr. Kabilian showed you. Continuing education and a number of these bulleted points are really important for all staff in their retention. Now, it's sad when we have to deal with termination and involuntary departure, usually involve professional HR folks. But if you're a small practice, you're not necessarily going to have access to that, but you may be able to outsource professional HR to help you with some of these various details that I've enumerated for you that you have to be diligent about when you're thinking about the need to consider terminating a partner or a staff member. Review that employment agreement carefully and thoroughly and have a plan. Make sure that you document well, what were the terms of termination in the employment agreement? What did that contract say? Is this at will employment or is it going to have to be termination for cause? Is there an opportunity for remediation? If there's physician or staff involuntary departure, is there something that needs to be negotiated? Is there going to be a severance package that you're gonna need to offer? Is there some potential for litigation or some tail issues that you need to think about? Make sure that all of these I's are dotted and T's are crossed before you proceed on the path to termination. There are some administrative tasks that you'll need to consider with outsourcing, billing claims, compliance, quality reporting, EHR. These are some of the best opportunities for outsourcing. You might be able to save money instead of doing these things internally. And you're going to help your staff with potential burnout by unburdening some of these administrative tasks and outsourcing them. Let your physicians and your providers concentrate maximally on their core competencies by hiring some of this work out. Of course, outsourcing can also be important in terms of clinicians if you need to do that. But some of the easiest places to take advantage of potential outsourcing are with some of these nonclinical potential utilities of outsourcing. So putting all of this together, the team is more than the sum of its parts. They're the members, the organization, the culture and leadership to consider. Dr. Zeisenberg and Kabilian went through all of these with you. And so this talk dovetails into theirs. Growing a successful team is difficult, effortful and expensive. So you want to keep that team together. You want to keep the successful team members you already have through successful retention, but you want to grow that team through successful recruitment. Recruitment of physicians, APPs and staff should be undertaken according to a plan accounting for current needs and for growth also. Successful recruitment and retention of clinical talent is a competitive process. Recruiting successfully means leveraging your competitive advantages and multiple resources. This will ensure success. Termination though is sometimes required and it also requires thoughtful planning, strict adherence to existing rules and regulations and consultation of HR and legal experts. Outsourcing offers you some agility and cost-effectiveness by bringing in temporary resources in some situations, ultimately a culture of servant leadership and environment that fosters personal and professional growth, values the members through attention to personal needs and competitive total compensation and daily professional and personal satisfaction is the winning formula for a harmonious and productive practice. Thank you very much. Okay, Dr. Martin, you do like to quiz the audience, don't you? Should we run those polls? That sounds great, Eden. So outsourcing involves, is it adding incremental talent and skills from within your practice or is it usually involves providing a benefits package to the employee? Or does outsourcing involve that it may lead to hiring directly and permanently into your practice or does it involve long-term commitments or does not lead to infusion of external ideas? Only one of those is correct. Which of those does outsourcing involve? And you nailed that one, right? Of course, it leads to the potential for infusing external ideas and that of course, it can lead to hiring permanently into your practice. This is important. It may actually be an audition after all, which can be a great advantage to you. So good job on that. Partners, staff and employees are, is it our second most costly resource for the practice or is it that they are a plentiful resource or is it that they are the most remunerative resource in the practice or is it that they are all licensed personnel? Only one is correct. And here's where we're at. You are superb, right? They are the most remunerative resource in the practice. They are actually the most costly resource. They are a scarce, not a plentiful resource. They're not all licensed. Nurses and physicians and APPs are licensed. GI techs are usually unlicensed clinical personnel. And we've got one more before we hand it back to Dr. Eisenberg. Features of your practice that attract new talent include opportunities for ownership and ancillary revenue streams, leadership opportunities, mentorship, research opportunities, or is it all of the above? All right. There is no fool in these folks. You got it. Whatever your practice's highlights are, put them up on top of the table. Let them know why you're the best. Excellent, thank you.

team building

medical practice

recruitment

retention

termination

outsourcing

team culture