What an amazing morning. And now that we've heard that well-being culture talked about, it's not the first time, but now we know how to be equipped with practical tools, how to translate it in our day-to-day practice. And let's keep the interactive discussion a bit longer, drawing in GI practice perspectives from the leaders from across the country and practice setting. To the panelists, I would like each of you to turn on your cameras as you're being introduced. Presenting private practice and private equity alliance, Dr. Vasu Apalaneni is an advanced endoscopist practicing in Dayton, Ohio, since 2007. She's currently the executive vice president clinical innovations at OneGI. Vasu currently serves on the ASGE practice operations committee. Also, welcome to a representative of private practice backed by private equity, Dr. Kamran Ayub, who is also an advanced endoscopist at Southwest Gastroenterology at Oakland, Illinois. Kamran also currently serves on the ASGE practice operations committee. Next, representing the private practice administrative perspective, Dr. Raula Jamal, who started her career as a doctor of pharmacy. Her experience includes research in gastroenterology and pharmaceutical manufacturing. Over the last 12 years, Raula has been an administrator at Oceana Gastroenterology Associates in Corona, California. Next, representing academia, Dr. John Martin. He's a full-time practicing gastroenterologist at the Mayo Clinic in Rochester, Minnesota. In addition to his clinical practice, John's interests include endoscopy unit operations and efficiency. John currently serves on ASGE practice operations committee, representing the community hospital perspective. Dr. Hilary Tompkins has been employed there since 2011 by four physicians, a multi-specialty employed group at the Exeter Hospital, where she is a practicing gastroenterologist and has served as a medical director of endoscopy unit. Hilary volunteer services to ASGE has included terms on the practice operations and health care and public policy committee. Thank you all for joining us today. And we look forward to you sharing with us your perspectives. So we have a few questions that we want to run by you, and I hope you're going to share your experience. I have a question to Dr. Jamal. Raula, in your experience, what are the top three factors that make staff choose to stay long-term in gastroenterology practice? And how can we better capitalize on this? And please welcome to share any of the tips to all of your panelists. Good morning, and thank you for having us today. And I hope that sharing our experiences would be helpful for other practices in the country to maintain their performance during these tough times that the country is going through economically and on the employment factor. We have, in our experience, especially the last three years, which is totally different than the whole career time, we have found that offering employees a good benefit plan, offering employees health care services has been my first and my biggest winner for keeping talents within the practice. The second thing that we have noticed as well, giving employees flexibility, meaning that we have to consider their personal life very deeply when they come and request time off for family or request time off on difficult times. We have combated that so we won't have a shortage in our clinical practice by hiring more part-timers or on-call people and put them on the side so that we would offer that flexibility for our employees. And actually, that approach has come to us only this year. And it's been very successful in maintaining our core people for the longest time. Other than that is changing the culture a little bit. We are all under stress to perform. And health care environment is changing tremendously around all of us. The high demand performance that we did not experience a long time ago, and now it's changing into this environment that we have to perform and we have to answer to a lot of entities, insurance companies, IPAs, have put us in this situation where we really have to change the within culture that we have among employees by offering them more into having days where we celebrate our successes. We announce our successes. We always educate our employees that every day that we go through is a success of its own. And that has been a very, very good support to them to show up this next day and be happy about what we're doing. So I think what we've talked about this morning with Dr. Safir, they are little things that doesn't come to our mind. But really celebrating these employees on the little things that they do, it's greatly appreciated. And they feel that they are connected to the bigger circle of performance. Thank you so much. Thank you so much, Rua. So we find in our practice also that we have to pay more and more close attention to employees well-being to trying to maintain that culture. It's really the job that never done. So I don't know if any other panelists have any other experiences to share what worked in your practices. Any success stories about the culture? Well, for some simple things to add, I think, Inessa, picking up on some of the themes that Dr. Safir was championing, we try not to forget that the social aspect of work is important. We spend the majority of our working hours in our jobs on workdays. And so de facto, that is a substantial portion of our social life that's spent at work. Work environment itself has limitations in terms of what you can really do with that. We all need to focus on the patient when we're at work. So we do try to throw social events that include everyone on the team, not just individual groups. So while there may be nursing staff-centric social events or physician-centric ones, we do try to make sure that there are a handful of social events planned by a social committee that includes nurses, providers, techs, basically everyone that's on the team to plan social activities where the whole team can participate and bring their families. Things like going to an apple orchard in the fall together or having a holiday party that doesn't happen at any particular holiday but tends to happen in late January or early February so that it doesn't get associated with one or two particular religions and also isn't impeded by the need for folks to go to their own family's holiday and religious celebrations. There are also some summertime events like pulling a pizza trailer into somebody's backyard, getting a DJ or a small band, or just music provided by people in our group who play music and just hanging out together at a low-budget event. And those things include all staff, from support staff through all the various clinical professions and unlicensed clinical personnel. Sounds like a wonderful team-building activity. We are trying to do something also on a scheduled basis. We turned our staff meeting into mini parties, and we're trying to do it at least once in six months, if not quarterly, so that we finish the cases a little early and it turns into a professional and social gathering because it's a more relaxed environment for those meetings. There's a little finger food, and it turns out that people are bonding and connecting in that type of environment very well. So that's a little thing that we implemented. So, but the practices are really changing, especially post-pandemic. One innovation that actually is sticking around is telehealth that has become increasingly prevalent. And how has this shift impacted the staff recruitment and retention in your practice? Have you seen any positive or negative effect? Dr. Kamran, would you share your thoughts on this? Q&A, sir. First of all, I would like to thank you and Dr. Safir, or Rich, as he likes to be called, for an outstanding workshop today. I really enjoyed it. I think it's very, very timely. The staff retention and staff hiring has become a major issue for most groups in Chicagoland where I practice. So it was very, very helpful. Telemedicine is new to us. As you know, it's only three years old, started in 2020 with the pandemic. And we are still building this ship as we sail it, so to say. And we are learning more and more about telemedicine and telework as we go along. There are a lot of advantages associated with this. So staff, we have access to a much wider talent pool. For example, one of our schedulers in our group, and we have a group of eight gastroenterologists and eight mid-level or APPs, one of our schedulers works from Arizona. We hired her. She doesn't like the Chicago winter, and I don't blame her. She lives in Arizona and does scheduling from there. We have some staff who want to work from home, who live an hour, two hour away. So we are making some arrangements where some of the staff work part time from home, part time they commute to work. It gives them a flexible arrangement where they can be at home with their kids or their pets or whatever have you, reduces their commute time. If they are commuting one hour each way, the commute can be tough. And it's a lot of gas, gasoline costs for them. And I think it improves work-life balance for the staff. So there's a lot of advantages. There is also, unfortunately, a lot of disadvantages. So first of all, some of our staff, when they work from home, they are not so proficient. These are elderly staff mostly, not so proficient with computers and Zoom and laptops and technology. They're not so gadgety. So that creates challenges for those staff. For the providers, some of the peers, for example, commercial peers like Blue Cross and UnitedHealthcare have stopped reimbursing for telemedicine. They want patients in your office. They have a separate, very minimal reimbursement for a telephone visit. So that has created some challenges. Some of the patients prefer to come to see the doctor. They don't want a telephone visit. They want an in-office visit, face-to-face, so they can be examined or seen. That creates some issues. And then staff monitoring can be an issue. So some of our staff are very reliable, hardworking, great work ethic. There are others who like to be on Facebook or Snapchat as soon as they get a little break, or if there is a phone not ringing, something. So it's very hard to monitor what staff are actually doing at home, and that creates some challenges. And lastly, I think that with Rich, John Martin raised this question earlier, how can we be fair to all staff? So one of my staff member got engaged. Her fiance lives three hours away. So she wants to come to work three days a week, work from home two days a week, which seems very reasonable, very trustworthy staff. But two others who live nearby are also saying that, oh, why can't I do work from home as well? And how to be fair to all these staff? You have to be fair. So those are some of the challenges, and I'd love to hear thoughts of other panelists on that. Overall has been a positive and negative impact on our practice. Thank you for sharing your experience. So any other experts on the panel willing to share how you're balancing those positive negative effects of telehealth? Okay, so- One of the other things I might jump in, one of the other advantages, Anessa, we noticed was, one of my PAs got sick with COVID. This was when COVID meant you're home for seven days or five days initially. But she wasn't feeling too bad. She was just COVID positive, runny nose, mild headache. She had a full clinic, and she was able to do that clinic from home by telemedicine. We called all the hospitals, and we had a full clinic. She was able to do that clinic from home by telemedicine. We called all the patients and said, hey, she's sick, she'll be doing televisits from home. Are you able to do that? Most of the patients agreed. So we didn't have to cancel a full day clinic. So that was another big advantage. Sorry for interruption. No, thank you for sharing. That's absolutely true. So I find one positive effect that we're trying to schedule the telehealth in one block time. It hardly requires any staff engagement. So it's mostly between the physician and the patient that you're connecting to one patient after another using the telehealth platform. And that gives your administrative staff and your support staff, your medical assistant time to catch up to their other office responsibility. So I find that catch up time is very valuable and welcome. So when they really are not pulled in many different directions, but they oftentimes have to multitask on a busy clinic day. So that's one positive impact that we've noticed, that catch up time. Okay, so. One of the other things we also noticed is that our practice grew. We used to be five partners and now we are eight partners and eight mid-level. We used to be three mid-level. So we have grown very fast and we have outgrown our space. We have the same office. So with telemedicine, some of the staff are working from home, but if they were to come to office, there is no computer terminal seat available for them. So that saves on the spacing as well, has been advantageous for us. Sorry. If I may add as well to the benefits of telehealth that we have seen recently, especially after we really got used to it and organized our workflow around it, that a lot of patients are requesting to use the telehealth venue, especially after they do all their workup and they need to just meet with the doctor for their results. And that's been a very good venue for us to decompress our clinics and the amount of work that we are doing through the clinics, rather open it up for new patients to come in. And the other advantage that we have seen, especially in our environment in Southern California, where we have to service bigger IPAs and bigger contracts is that we were able to service patients remotely that were referred to our practice for very high therapeutic procedures without having them come from very far places. So the only travel that they will make may be to the facility to get their procedures done. Totally agree. Yeah. We've seen that too. I think Vasu has something to add. Definitely one of the advantages to spare a patient an extra trip, especially if they live in a very remote geographic area. Inessa, following up on Cameron's points, I definitely, I meaning our company and myself are definitely proponents of the flexibility. As he said, some of the employees wanted to work from home and followed by some of them wondered as we are growing bigger organizations, we do not have enough space for all of us to accommodate. They both balance out each other luckily, but if the job is being done, quality work is being done, and if the employee is happier staying at home, doing the work and getting the work done, we should be flexible and be agile to the changing needs of the next generations. That's the point I want to make. That's an excellent point. I actually have another question for you, Dr. Polinani. So if you can share, Vasu, if you can share with us how you handle internal promotions versus external hiring in your growing organization when the key position opens up, what has been more effective in retaining the cohesive team? Thank you, Inessa. And excellent program. Good morning at 9 a.m. Great to see all of you. Coming back to the promotions, I'm a big proponent of talent recognition and retention. If a key position opens up, a leadership position especially, I would recommend looking internally, benefits. You know the person already, what their work ethic is, what their culture is, what their values are. You don't need to have extra time to train them, onboard them. Three, it can be less expensive because of that. And you don't want, at the same time, you wanted to understand or not create an internal fight with having several people fighting for the same role because we all work together. Even if you pick one person to come to that role, they would need to work together with the other person that are competing for the role. So it's extremely important to maintain that culture. I believe the way I would work that around and we were working that around is giving effective feedback. You should be knowing at certain point, you cannot be getting great reviews, you're doing a great job. And when it comes to promotion, sorry, you're not fit for promotion or we cannot get you up. That surprise cannot be there. One of the favorite things I remember from our business school professor saying, when you give effective feedback, the manager should be able to say, I'm surprised you're surprised. There should be clear expectations on how the job is being done, what they bring to the table and what are the growth opportunities do we provide. Unless we keep the staff engaged, empower them and give them growth opportunities, seeing because not everybody's looking for growth, but there are people who are very motivated, talented and would like to grow in the organization, be a mentor, be a sponsor, try to identify these people ahead of time. As soon as a senior role is hired, I think the succession planning should start then because it does take time to identify whom to nurture, whom to groom, what leadership qualities are we trying to help them attain, trying to build a process. That's how I look at it and that's what would bring definitely better values. There are certain times you may not have an internal talent and you have to go out. Obviously, looking outside does help so that you can compare and you have a sound decision being made. I still, compared with outside people, still my inside person is the best one. The why behind why you are keeping your internal talent or promoting is key. If any of my panelists have any other thoughts, happy to learn from you as well. Thank you. I totally share your excitement about giving the opportunity to people that have been with your company for a long time and distinguished themselves as the leaders. Any tips on how to support that person that you recently promoted to make sure that it doesn't create a culture of resentment from people that used to be the peers and now they supposed to report to that person? I would say giving clear expectations to them. This is what we are looking for. And if they attain those, I mean, in the business world, they call those KPIs, but it's just more than hitting the numbers, but it's a lot of things. How do they have relationships? What is their culture? How do they behave with people? What is their attitude? Do they have compassion, empathy, different things? You are keeping on analyzing and they know we are being evaluated not at the end of the year. The feedback has to be continuous process. The sooner you can give a feedback, the better it is so that they have clear knowledge on, oh, I may not be the right candidate for this. This is what we are looking for. And this is what I was able to achieve or not able to achieve. Having that line would help. Dear panelists, any other thoughts on this question? If I may add to all that great input is that when you have a new talent, you always have to keep in mind that you need to be available as a mentor, especially whether it's a talent that's within the organization and knows the workflow very well, knows the people, knows the culture. Promoting that talent into a management role is a difference. So as a manager or as an administrator, you have to always tell your talent that they have the support that they need and they should not be afraid of making any mistakes because that's the biggest issue with internal talents that how about if I fail? How about if I make mistakes? Am I gonna be held accountable? So making mistakes, if you turn it into a positive learning experience to those managers and make it public that we are not here accountable for making mistakes, but we are here to learn from the mistakes so that it would not become part of a bigger problem. The support is extreme key to have that internal capabilities or internal talents to want to be in a management position. And the same for any outside management recruitment, they have to have that full support. In my experience, the support for management is about four to six months until they are capable of being comfortable making the decisions and the changes that they need to make in the culture that they came into. Thank you. Thank you, Rola for these comments. I actually wanna pick your brain on another problem is in a rapidly evolving GI field where we have new technologies, new methodologies that becoming a fast common practice in our daily lives. How do you address the skill gap in your team in this dynamic environment? Absolutely, training is the key for all that, being out open, having meetings, updating your staff on any type of technology that you're gonna be introducing into the practice. Introduce the technology slowly into your practice, don't implement it in masses. In our experience, we have done that before and we failed miserably, especially during COVID when we were trying to figure out this new norm that was imposed on us and we didn't know how to handle it. So we implemented some different technologies into the practice, whether it was texting and opening the texting capability to patients, thinking that this is gonna be a better communication than you without wasting time on the phones, which failed miserably in the beginning because patients wanted to talk to people during COVID and texting was an open chat that you couldn't end. So that's one example, but in my experience, when you are to adapt any new technology into your practice, make sure that you adapted on a very small scale. So for us, it has worked where we have an office that's not as busy as the other office. So now we implement any new technology or any new adaptiveness, we take it into that small scale office with less employees, we train them, we make them capable of using that technology and then we get the feedback on how is it working? What is the satisfaction rate with patients? What is the satisfaction rate with providers and other offices? We take a whole environment survey into that technology and then we look at the financial aspect of implementing that technology and how is it affecting our budget? If that all goes very well and appropriate, and I think the timeline in our opinion, where we implement these technologies, you will see the fruit of whether it's successful or not from four to six months. So we implement it, we keep the feedback about how it's working and then once it is successful, we transfer it into a wider scale with very intense short-term, not short-term, in short periods training. So we train a week after a week after a week and then we break the training into longer terms, we take feedbacks, we improve and then it will become the second norm in the workflow and within the practice. Sounds like a very thoughtful and measured approach. And so we know that the medicine is ultimate, especially GI field is the ultimate team sport. So we need multiple team members at every stage of the operation, from the front desk to medical assistant to endoscopy nurses and endoscopy technician, APPs, doctors to work as a well-oiled machine. And I wonder in which group of staff do we have the greatest deficits and difficulties in recruitment and retention? Because every team member is absolutely invaluable to ensure the smooth operation. Dr. Martin, would you share your thoughts on this? It's a complex topic for sure. And one of the reasons why I have great interest in it, particularly in large organizations, you have a lot of different types of licensed clinicians as well as those participating in clinical work like endoscopy techs who are unlicensed, who are technically working under the license of nurses, right? Although my experience, which is in large organizations only, is that the techs don't always see themselves as reporting to the nurses that they work with. Regardless, in the same environment, you have providers like CRNAs and physicians working side by side with hourly employees like nurses and techs. And so the pay satisfaction or pay dissatisfaction is going to be very different depending on what the pay model is. Does that make sense? And so the scuttlebutt that you hear, I think amongst the different employees is equally distinct. What I hear hourly employees complaining about in my own institution is that there is a pay delta between inpatient and outpatient nursing staff, for example. Or we have three endoscopy units and they don't all take call. The routine endoscopy unit nurses do not take call. But their pay isn't different and can't be within the confines of the Department of Nursing where you have thousands of people who have to be basically treated the same way when it comes to their compensation. This is further complicated by the fact that there are licensed practical nurses, which in some states are called licensed vocational nurses, LPNs or LVNs, who function in some roles, particularly in technical units like endoscopy, nearly the same way that the registered nurses, many of whom are required to have baccalaureate degrees, not just hospital trained, perform. And so there are going to be situations where the LPNs or LVNs feel that their lower pay per hour is not justified when they see themselves as performing the same work, even though their responsibility levels may be different. So those are some of the touch points that I hear in terms of hourly employees. In terms of providers, our CRNAs are not hourly providers, they are salaried. Yet we're faced with the same shortages of CRNAs. It may even be more acute where I work than elsewhere because the compensation arguably can be better in practice, smaller practice settings and clinic settings for some of these individuals to perform office anesthesia on a per patient basis. Nonetheless, they're salaried in the large hospital environment. But particularly with the shortage of these personnel, we have situations where they're obligated to work late hours on certain days and their compensation is not going to be time and a half or double time like it might be for hourly employees, but instead is going to be provided as compensatory time where they might be able to leave early on another day if there's low census comparatively. But on those days, that's not planned early release, it's unplanned and so then the time becomes less valuable to them on a personal basis. And so that inability to control one's time outside of the hospital, particularly in this day and age when many families have both parents working in such roles is some of the dissatisfaction that I hear. And it has been very, very challenging to find solutions because it's so difficult to recruit when there's such a shortage of these professionals. Definitely, it's a very complex environment that we live in. It is, and I could go on and on, but I don't wanna monopolize the discussion, but I'll leave it by saying that there are also discrepancies between departments. We lose people all the time internally, which is to say that we lose them to pediatric clinic or to urology or to cardiology because of pay deltas per hour, or because at peripheral sites, there might be free parking and no call and no weekends to work, no evenings to work, strictly eight to four, and just easier to control one's family life as a result. And the institution has no incentive to keep these people on the same unit because they'd rather have them stay within the enterprise than to leave the enterprise and go work at a competitive institution. So these sorts of things, or in an effort to make things fair for everyone, there's no longer any advantage to maintain seniority. So people will leave the institution to get a bump or to get a leadership role because staying longer doesn't get you anything. If anything, you may be paid lower than somebody who is a new recruit and might have new skills to act to the practice. So lots of challenging inputs that can be very different between small, medium-sized and large organizations. Particularly in terms of how directly your leadership is able to effect change. There are a lot more layers at large institutions which makes that more complex to navigate. Thanks for the opportunity to discuss that issue. Thank you for this perspective. Definitely very complicated situation, but again, emphasizes the importance of creating that culture environment where people feel comfortable, create that family feel, that wellbeing culture that might be one of the incentive to stay on the team. So that could be just one of the things that will keep the talent inside. But from a community hospital practice group standpoint, what are the strategies that have demonstrated success in improving the access to healthcare and provide the recruitment and retention in your practice, Dr. Thompson? Hillary, would you share it with us? Yeah, so I'm in New Hampshire and our unemployment rate is 2%. It spiked obviously around COVID, but it's gone right back down. So finding people to do probably the most important jobs that a lot of us see openings in just medical assistants, LNAs, taxes is really difficult in our area. And I think it's become more difficult. A lot of what people have commented on, we see it too, and people wanna work remote and they wanna work less hours. They wanna work part-time. They want more flexibility. And sometimes that's difficult as we've sort of said in our positions where we have patients coming in all day and there's a need for people to be in the office and not always remote. So we do a couple of interesting things, I think. So medical assistants seems to be one of the things that's hardest to employ and hold. And I think it's because of the level of their sort of job and their pay and they're in the beginning of a career. And so they like to move around and a lot of them move on, which I think is great. Our hospital actually, so I'm in a multi-specialty group. We have three currently gastroenterologists. We're down one. And so we primarily work in the office that's associated with the hospital. And actually we just merged or was bought out or something by BI Lahey. So everything's sort of in a flux. So we might have a bigger system to be working in. But so our hospital and our program across the board, our physician group realized that medical assistant recruitment was really difficult. All of our practices across all of our specialties in internal medicine are in need of medical assistants and LNAs and actually nursing. So one of the interesting programs I think that we've done is the hospital and four physicians partnered with one of the medical assistant training programs through one of the community colleges so that those students would come in and do all their like training and clinical experience in one of the offices. So we've had some in our GI office and often what we found is that leads to them staying after their training program and their medical assistant program is done. So they've already seen the office that we've met them. They've kind of learned how it worked. And so we found a lot of recruitment and retention in that level through there, which I think is an interesting program. We found that I think internal referrals so a lot of times so we've been really pretty short staffed in our in our GI office especially in the nursing aspect and part of that is because our office is really busy and I think GI is has lots of patients calling in and needs a lot of prior office and all that stuff that falls on the nurse and and so we've run into the we want the nursing wants to be remote part-time home sometime or just more set hours so we've really worked on making flexible schedules doing part-time in the office and allowing a part-time nurse or having a second nurse kind of work opposite schedule doing some remote work when we were down a nurse we actually had some nurses who from other offices and other programs in within our physician group who were floating into our office so the benefit of being in a big physician group is that MAs and LNAs and nursing can float between practices because they're all really employed by the same group and we found that in that way not stolen but sort of people found that they that they fit better in another office than where they were and we've had that happen to us too or we've had nurses leave to go do full remote but it brings in people who kind of test the waters and then they want to stay more because they've experienced really what it's like to work with us so we have a nurse that's part-time right now who came in and helped and she really wanted to stay and so we were able to accommodate that so those two programs kind of allowing people to have a little bit of a chance to see what we're like before committing long-term has really helped I think get the right people into the office. That's very interesting. Yeah and we also have one other program I think for the MAs that helps to keep them as we have a results a rewards for results program so when it's actually not just for medical students it's for anybody in the office if they if they have something that they've done they've really put in a lot of extra effort or we've recognized that they've worked harder than than normal because of situations in the office then they'll get like a little gift card or a little bonus or something just recognizing their effort and that really goes a long way I think again celebrating the positives making them know that they're part of the team that we appreciate them and that the patients appreciate them really goes a long way and retaining people once you get them into your office. Positive reinforcement and encouraging this behavior where they put an extra effort into their work and they're proud about their performance. Certainly, so I just want to ask Dr. Apollinani to share with us if there are any strategies that have been successful in your practice in increasing nursing work-life balance and what if there are any failures that you want to share with us as well. Sure, it has been a hot topic right all morning we are hearing work-life balance which is extremely important in all the teammates that we work with. Coming with nursing staff I have an example from our own practice we are 24 gastroenterologists with several app so our indoor schedule runs in three different practice buildings. Having procedures scheduled in a block time where we think is the right but it may not be the right for the nursing life schedule. For example, we changed the last case of the day from four o'clock to three o'clock after analysis. There was a significant dissatisfaction because even though we do the case at four and it ends at 4 30 the staff needs to stay longer than what we end up staying as physicians. Significant dissatisfaction of course if rooms run late and some are slow docs some are mediocre some are fast docs so we all may not end at the same time. So that creates some dissatisfaction you know I don't want to be in that room or I want to be with this doctor you know you don't want to create these favoritisms but at the same time we want to let people go to their homes have some predictability in their time when I can get to home when do I need to pick my kid who should I ask help from anybody so having that helps. Coming to physicians wise you know it's extremely important that we being the significant workforce behind the whole organization many times we don't take care of ourselves which is extremely important having a work-life balance. I call it work-life integration because I don't know if I wanted to do well in one area and you know trying to balance these but sometimes you may not draw a line you know though we want to draw a line I don't bring work home but if if an activity happens that your kid has a practice or they need to be picked up and you have a couple charts to be left and you need to document tonight maybe that's the only day you bring it back home but if you need to take your kid to work because there's nobody else to take care of you know they have some little runny nose or so forth so that that flexibility of having integration definitely helps. You asked what didn't work too I would tell an example of we having cookie cutter schedules like this is what we will do for everybody. We all are busy we want to take care of patients with good quality and be accessible so when we are at work we want to work at max capacity but when we created a protocol to optimize you know FTE staffing we said maybe this number of physicians or staff need to take off in this quarter so that we have good balance on who takes off at what time. Significant dissatisfaction because you cannot tell only three people can take off in this time. What do the other people do? So we had to let go of that and create a habit of we all are vigilant and mindful of the expenses if all of us take off at the same time that's difficult but how do we troubleshoot that at the same time giving the capability, control, autonomy on trying to keep your vacation schedule because this is a significant wastage of dollars that can happen if we're not mindful but at the same time we have lives on the other hand so maintaining that was a challenge but we were able to overcome it with open communication you know building the trust you know so on so forth. Communication is extremely important and understanding each other. Individualization is a key that I would take because a schedule that works for me may not work for you that doesn't mean my schedule need to be rubbed on yours so we need to individualize just like the patient care we are all human beings too so some things work for one person may not work for the other and the leader need to be mindful of that. Thank you, thank you for sharing your perspective. So of course it's about well-being, team building activity, flexibility to the approach as you said not a cookie cutter but the culture creation is a complicated process and we cannot really meet the pay out of this discussion. So Dr. Martin, do you perceive more dissatisfaction about hourly pay or about total compensation or about compensation models because no matter how much culture we create a financial aspect is extremely important as Dr. Safir pointed out that it's a high stress level about the financial situation that our employees might not be sharing with us so it's always on the background and are these pay discrepancy within your institution that might be contributing to this internal transfer of stuff that disadvantages your specialty? Yeah another very complex issue right up there with recruitment and retention which I might just throw in there that if I had to answer in a very simple fashion whether I think that my own organization does a better job of recruitment or a better job of retention, I frankly think we do a better job of recruitment. I don't know that we have a highly formulaic approach to retention and I think there's a lot of opportunity there which is a nice way of saying I'm not sure we do the best job of that and we need to do a lot better than we're doing. Now it depends like I said earlier on what you mean by that when somebody leaves to go work in oncology I consider that a loss. My enterprise considers that retention. It's not retention to GI though and so you know my cost center is what I'm interested in and therein lies the rub. With large organizations you know the the leadership of any work group is many steps away from some of the core and key decision making so it makes it very difficult to effect change that might be most impactful within your own work group and so while it may seem intuitively contradictory in large organizations where you seemingly have greater potential for coverage and more cushion and things like this, the end effect that isn't necessarily going to net you the result that you're looking for so it can be complicated. To expound on some of the themes I touched on earlier, the pay dissatisfaction is there regardless of which pay model we're talking about. I have always worked in large organizations and the providers whether they're physicians or APPs and I include CRNAs within APPs because they're providers too and I work with them every single day all day long and hear their complaints. The providers, APPs or physicians are all salaried at my institution. It's straight salary period end of story and the nursing staff are and the unlicensed medical personnel the tech so to speak are all hourly if that gives you a clear picture the hourly employees without a doubt their dissatisfaction has to do with things like the differential between inpatient versus outpatient nursing pay. The inpatient units are harder to recruit to and harder to retain within and therefore the department of nursing which we don't control they are their own department sets deltas in salary between inpatients and outpatients and so one of the innovations that we worked on because we had a revolving door of nurses being recruited to GI endoscopy and then exiting within less than a year was that at least for our unit that sees some inpatient work we construed things where we run the unit as a 24 hour a day unit even though we don't typically have cases going on within the unit 24 hours a day and most of the the bleeding stuff that's handled in the middle of the night obligatorily occurs in the ICU. We've been able to construe things so that there is a night shift endoscopy nurse who if not engaged in you know acute bleeding procedures in the ICU is doing things like stocking and ordering and getting the room straightened out and things like that and so there's one person getting that wage overnight and that allows that has allowed us to construe that entire unit as a 24-hour unit and therefore gets bumped up to inpatient level pay. So we've been able to greatly mitigate people going out the revolving door to go to other units and work groups within our institution. The CRNAs are tough. They're salaried. They are part of the Department of Anesthesia. They are not part of the Department of Nursing and they are salaried the same way the anesthesiologist physicians are and therefore by having to work late on some days where there's high census they are essentially compensated by being given comp time on another day. Their complaint will be well I'm given an early release on days where I didn't plan for that so that time's not useful to me. I'd rather be paid time and a half or double time but since they're not hourly employees that can't happen. There isn't a mechanism for that within our enterprise's compensation system for providers. The same is true of providers APPs in the clinic. So this has led to some difficulties in retention when there's already a heck of an acute shortage as well as a chronic shortage actually even though we have a training program for CRNAs at our institution. We lose a lot of those trainees to other metro areas particularly when they don't want to stay in the rural area that our hospital is in. So bottom line whatever the compensation plan is whether it's salary or hourly we have dissatisfaction that seeps through to things that ultimately impact on quality of life. I think we found an innovative solution for nurses in one of our endoscopy units not necessarily in the other two. We haven't found any solution for the CRNA thing and I'd love to know what some of you are doing because I know everybody has a shortage of hands on deck when it comes to anesthesia providers. Thank you for the opportunity to address those concerns. Thank you. Thank you John. So any innovative ideas because I think we are running to the top of the hour so any practical tips that you can share with us and our audience? Just one thing to add on on the anesthesia shortage saga that we're seeing all over the country is that maybe adding to the staff and per diem staff or per diem anesthesia company that could be incorporated within the workflow of the workplace whether it's a big organization or it's outpatient basis I think would be helpful if the organization and the bureaucracy would allow that. Thank you. Thank you Rola. Any other thoughts? This is Cameron. We have had a huge shortage of CRNAs and a revolving door as well. We increased the salary. They wanted more guaranteed hours so even if we work for four hours they won't pay eight hours guaranteed and we did that. They don't do night or weekend. We have an ambulatory So I think that there is a nationwide shortage of anesthesiologists and CRNAs and has been difficult to tackle this problem. I would like to echo all the problem that John is facing in a big organization we face in small organization and in my hospitals too. I go to two hospitals, a teaching and a community. They both have similar issues as well shortage of CRNAs. I think the solution long term will be to open more schools, increase the number of graduates going into this CRNA training. So there is a balance, supply and demand balance. Cameron, I actually wanted to ask your opinion. How important do you think their pay is? How important do you think their pay is? Is it all about the pay or do you find that your employers put emphasis on other aspects nowadays? I think that the pay is extremely important. Money makes the mayor go. So I think pay is extremely important but there are other aspects. So we are a big group, GI partners of Illinois. We have five, six different subgroups. My group, Southwest Gastroenterology, has eight gastroenterologists, eight mid-levels. I have my own SBU or strategic business unit within those eight and I have 12 employees of my own, 12 staff. Four of those are advanced practice providers. Two of those in the last year had babies and decided to cut back. They wanted job flexibility. They went back to three days a week. So they took a pay cut. Obviously, there's 60% FTE. But one of them said she wants health benefit, health insurance and GI partners regulation requires them to be 75% FTE to get health insurance. So I was flexible. We gave her 10-hour, three-day, 10-hour shifts. So she is 75%. So flexibility is extremely important to the staff as well. Some of my staff like to come in at 9.30 a.m. Others like to start at 8 a.m. And we have been flexible. We have tried to match them, the APP, the MA. So when they come, they can have a clinic or start working that way. I think ability to work from home, as we discussed earlier, has been an important adjunct as well to job satisfaction. Benefits are extremely important. The pension plan, the year-end bonus, the raise every year, all those things come into play. But the other things that I use is job security. We tell them that, hey, we are in it for long haul. Once you join this place, you're not going anywhere. They have the job security that they will not get laid off if the volume drops or anything. And to me personally, and I think to my staff now, my APPs, most important thing is what they excel at, to do what you enjoy. So I enjoy advanced endoscopy. I have to go to an ambulatory surgery center because I'm part owner and medical director there one day a week. Don't enjoy it. I'm doing EGD colon. I go to hospital all day. I'm doing ESD, EMR, ERCP. I enjoy that. So those days are very long days from 7am to 7pm, but there's no burnout. I enjoy it. So I'm getting paid to enjoy myself. Same thing with APPs. One of my APPs was very interested, intrigued by capsule endoscopy. She reads more capsules than probably any APP in the country. She reads about 240 capsules a year. I made her the capsule expert. The other APP was not so interested in capsules, but was enjoying doing esophageal manometry. We trained her in enorectal manometry as well, made her membership of neuromuscular society. She enjoys manometry, so that is her enjoyable part of the work. Obviously, the bulk of work they do is seeing patients in the clinic, but then this part they enjoy. So, if they do what they excel at and what they enjoy doing, I think that improves job satisfaction and makes the job more important and satisfying to them as well. Work-life balance has been beaten to death already, and I mentioned the three-day work week and four-day work week, working from home. But I think work-life balance, job satisfaction, where they enjoy what they do, are almost equally important to salary. Obviously, if somebody else will offer them double salary tomorrow, it will be hard to retain your staff, and that's what we are seeing with CRNAs. They get a $50,000 bonus, sign-on bonus, and a big raise, and they leave. They go to remote areas. But other than that, I think some of the things that work that are important is job satisfaction, work-life balance, the benefit package, and obviously, if you enjoy something, if you excel at something, you're giving them that area. So, those are some of the techniques I use. Thank you for your input. Dr. Martin, did you have something to add? I saw your hand up. Well, I know that our time is getting short, and Cameron really addressed much of it. So, thank you for the opportunity. We're good. We actually have time for a couple of more interesting issues to address. So, I know that diversity, equity, and inclusion are increasingly emphasized in the healthcare setting. So, we have representatives from a variety of practice setting. How are you incorporating these principles into your recruitment and retention strategies? If I can ask you, Cameron, to comment on that. I think that you asked a very appropriate person. As I mentioned, our group is eight providers and eight APPs. We have the most diverse group I have ever seen. I call my group United Nations of Gastroenterology. We have physicians who are Jewish, Muslims, Indian Americans, Arab Americans. We hired a woman gastroenterologist a few years ago. So, we have a diverse group of physicians. And actually, the diversity is our strength. We have a rapidly expanding practice, all of us. I think one of the major reasons is diversity. The Indian physician, all the Indians seem to go after him. Many women want a woman gastroenterologist doing their colonoscopy. So, guess what? They have long wait lists. We have physicians who speak Spanish, and all the Spanish-speaking people gear towards him. If you have a Polish-speaking physician, we have a large Polish population here in Chicagoland. They have huge practice. So, I think diversity is our strength as a group. Diversity is very important in workplace anyhow, because it expands the talent pool. The talent that a Chinese doctor brings to us or an Indian doctor brings to us, it basically is different from talent that we can get from home from a graduate. So, I think it expands the talent pool. We have a policy of actively trying to hire people based on their talent, regardless of their ethnicity, their race, religion, gender preference, et cetera. We, as a group, GI partners, actually legally has to do training once a year. All the staff have to attend a workshop that Illinois State Board requires that medical board. They have to attend online workshop on workplace diversity and those kinds of issues, all those issues about that. We also provide an environment for all our staff to be able to practice their religion, their culture, or whatever have you, without any fear. So, some people want to offer prayers on Fridays. We give them break on Friday afternoon, 12 to 2. If they want, that is guaranteed because it's their religious or cultural background. We try to respect their culture. We also have an environment of open communication. So, if anyone has any issues, if they feel uncomfortable practicing their cultural or religious beliefs, they're able to come to me. I'm the kind of acting manager of my group as well and complain about it. We encourage that and we try and take immediate action so they feel more comfortable in this environment. So, those are some of the steps that we have taken in our group, but we were fortunate our group from the start is a very diverse gastroenterology group. So, obviously, it starts with the leadership to make everyone feel welcome and embracive of the cultural differences. Vasu, do you have any comments of how you dealing with the diversity world in your practice? Inessa, were you asking me? Yes. I had some freezing off because of some unstable connection. It is very well received. We've been in existence in the local community for so long and being a 25 physician group, we have different religions, different races being represented. We realize the significant need for women in medicine, women in GI, women in leadership opportunities. So, definitely being a component, there can be more work done. We're not quite there yet. Obviously, we want to keep looking at what are the opportunities, challenges I see them as opportunities and we continue to embrace. Definitely, as Dr. Cameron was talking, the diversity brings mostly the talent diversity, intellectual diversity. Even though we come from different places, we have different experiences and we bring different talents to the table. We're losing out on those if we cannot embrace that situation. Thank you. So, can you all share something that you're currently working on trying to improve in your practice setting? So, what are the active projects? What's an acute issue for each and every one of you? What's keeping you up at night in your practice? Hillary, would you share your thoughts? So, I think our big issues are growing our practice with physicians and APPs and the volume in the practice is huge and we don't have enough people to accommodate it. So, one of the projects and things we're working on currently with the staffing that we have is really how do we appropriately bring in consults and process them and work with the community physicians and our own core physicians to have patients taken care of in a timely manner and then when is it appropriate to send them back for care through their primary care so we're not keeping all those patients in our office and to open up time for those patients and new consoles that need to come in and get into similar to endoscopy as well like getting access to volume and appropriately scheduling people so that we can accommodate all the volume in our small practice that needs to be accommodated. Big challenge. John, would you share what's keeping you up at night? Yeah, I think for us without a doubt it's meeting patient access demands. I just you know don't feel like we're doing the best job at that. Some of our wait lists are way out. They're better than some other departments. You know, I can tell you that my PCP ordered me to get a sleep study and so when their office called for me to get scheduled for that I was told that there's a six plus month wait and that they'd stick me on the wait list. So, I guess if I live long enough I'll find out whether I get an appointment next year or not. But ours isn't that bad but some of our endoscopy is out a month which is unacceptable because that has domino delay effects on the other departments that are requesting the procedures from us. Yet, you know, we don't recruit additional physician staff or additional nursing staff just because we at our own department level feel that we need those resources. We're allocated those resources from upstairs by the enterprise and they may or may not allocate that because they may or may not be interested in growing the GI endoscopy program. And so therein lies some of the frustration of what you can affect when you are many layers from the executive level and I mean that literally the level at which you can actually execute these changes that are necessary on the ground level to meet patient access. I truly believe that it's all about the patient and we're all patients too so we know what it's like when we call and we can't get an appointment and we've got a problem that needs to be solved because we have to make it through each day. And so we know what it feels like to be a patient and we want to please our patients but then when we don't have the resources to do that in a way that's reasonably satisfactory to a reasonable patient's request that's highly problematic. And so access is the problem not being able to recruit or not having enough professionals to be able to recruit as a problem. We hope that technology can solve some of those problems but it's not going to solve all of them and seeing people virtually is not going to solve all of them and we're in a hands-on business. We need hands on deck and the trouble is not having enough hands on deck. That's what keeps me up at night. Thank you. Thank you. Definitely a difficult dilemma how to maintain that work-life balance and ensure the access to care. Vasu, what's on your mind? I definitely agree with John on all those aspects. A few things that I continue to work on as with my role as the EVP of clinical innovation with a bigger group in different practices in six different states. How do we build a culture that keeps us going for a great goal? Patient centricity is completely important. I mean, I agree with John. It shouldn't be just a buzzword. We need to walk the talk completely. Revolving around that, building a culture that keeps us all together going towards the goal. We can build the best strategies in the world. You probably heard culture eats strategy for breakfast. You can find the consultants, great, have a board meeting and figure out the best strategy. This is what works for our patients, for us. But if we do not have a culture in the corporation that can help us get through that from point A to point B, it's going to be hard. That should be our competitive advantage. How we bring all of our people together in our organization. It could be an MA or it could be a physician. It could be a patient. Everybody together. Building trust. Changes are not easy. We are talking about multiple changes. I read a book, and if anybody is interested, The Human Element. What stops us from changing? We all love status quo. Changing is hard work. There are frictions. Why do I need to change? Why do I need to follow this new AI thing that you want to implement? Why a new HR? Different things. That's what I learned as I'm interacting with more and more people, being the change agent. What do I need to do if I'm in their shoes? What stops me from implementing this new change? Having that reflection definitely helps. That's what I go by. Thank you. Thank you, Vasu. Rola? So my last input on that, what keeps us up in these days is the cost. We are going through an amazing inflation. It's a positive negative word. At the same time, the reimbursement is very low. The capability to get our hard work paid, the chances are high not to get paid on certain claims. So with all that putting together, we don't have enough hands to work. We have too many patients. We have to meet access. We have to meet restricted utilization or overutilization. There are a lot of goals for us to meet, especially in our environment in the West Coast with the managed care heavily there. We have, in my opinion, we have to really outsource. So in order for us to keep our staff, the current staff that we have happy and use them at their maximum in benefit to our clinical workflow, the administrative work has to be outsourced. In my opinion, we have tried that. We came to success with it. I think the market is ready for that. We have a lot of companies out there with tremendous amount or huge capabilities of human resources that are trained on our workflow in health care, and they are certified. They do have certified talents, and they work all remotely under different umbrellas. We could outsource certain aspects of our practice and keep our local employees to be supporting our clinical access and the face-to-face interviews with our patients. There are different names that we've tried. We tried different resources. We found that they are really evolving, and they are really meeting our expectations the same way that a local person would meet, and that has elevated a lot of pressure on us not having people coming to work on certain aspects, and the patient's need for care has been met because someone is always working on their paperwork, whether our person in the office has come to work or not or have taken a leave away. That helped us keep afloat. In addition to that, as Dr. Martin has said, technology is really far from what they say they are in helping health care, but we keep the trust that they are evolving really quick and fast. We as practices, we always have to have the explorer like Dr. Vasu to always look into these technologies and where they are in helping practices keep afloat and keep their posts down in these days. Other than that, we are all innovative people. I thank you all for being here and having me and hearing my words, and we are all at this age after COVID, we are forced to be open-minded to see what other things we can incorporate in health care to help us go forward with what we need to achieve for our patients. We're forced to be resourceful, and we have to adapt. Dr. Ayub, any final thoughts? I think I tend to agree with the panel. What they said is all very, very true in my case as well. I wear a few different hats. As I mentioned, I am acting manager of my private practice group. I'm also a medical director of endoscopy at one of my hospitals, Silver Cross Hospital. Different areas have brought different challenges and given you different reasons not to sleep at night. But for me, in the current environment, the main challenge, the main concern has been hiring and keeping some type of staff. Number one, MAs in my practice, and number two, CRNAs for our Ambulatory Surgery Center. Both those have been a big challenge, and today's workshop was an eye-opener, was very, very topical. Really, I think this is the problem that many practices face today, is how to hire and how to retain your staff. And that has been a major challenge for me. People set up appointments for a job interview, don't show up. Don't answer the phone. Don't even make an excuse why they didn't show up. It has been a difficult, challenging time lately. The unemployment rate is extremely low, and for medical practice to have, because we are dealing with patients, we need to have people who can take good care of our patients as well, maintain that quality as well. To maintain quality and retain staff has been a big challenge, I think, for us. But I agree with the panel. Otherwise, everything else obviously also applies to me as well. Dr. Heikes, I have the very unfortunate news of saying we've come to the close of our presentation. It's been wonderful. Do you have any final comments before I do those last housekeeping bits? So, thank you so much for all the participants. Thank you so much for our wonderful faculty. And I also want to extend my special thank you to the ASGE team for their hard work in organizing this event and give us this platform to exchange the ideas, to fill that community that we know that we are not alone. We're all struggling in different parts of the country, different practice settings, with the exact same issue. And we have this opportunity, unique opportunity, to bounce ideas around one of the most thoughtful leaders in the field. So, let's continue to apply what we've learned to improve our practices. And let's take care of yourselves, of your team, and of each other. And let's stay connected. Thank you all. Congratulations on a wonderful event to you, Dr. Heikes, and to the whole panel. Our thanks to the faculty and to you, our participants. As a reminder, each of you will have ongoing access to the recordings from the course via GI-LEAP, ASG's online learning management system, when they're available in roughly three to four weeks. The course evaluation is now available in GI-LEAP, and once you complete it, you can download your certificate. If you need assistance logging into GI-LEAP, please email practicemanagement, all as one word, practicemanagement at asge.org. This concludes the workshop, Uncover What's Missing in Staff Retention and Recruitment. We hope this information is useful to you and your practice.

recruitment

retention

gastroenterology

work culture

flexible work arrangements

growth opportunities

skill gaps

training programs

telehealth

access to healthcare

staffing shortages

work-life balance