final Q&A session. And to see, we might have some stones that we have left unturned. Eden, do you want to take us into the next Q&A session? Absolutely. You know, we're going to go back to two questions that came in early in the day, which is really about employee management. So if folks want to go ahead and keep adding your questions into the Q&A box, and again, the Q&A box is preferable to the chat. That way, we're kind of centralized in one location. So again, this takes us back to earlier in the day. And the first question is maybe too broad of a question, but do you find bonuses versus raises to be better accepted by staff? Are they more effective for retention? Thoughts on that? Interesting question. You know, I think that on the one hand, bonuses are immediate. It's like an immediate, you know, a certain amount of cash from employees. And I think, you know, that has a certain impact. Whereas, you know, you raise salary, that happens over time. So they won't see that, you know, as easily, obviously month to month or every two weeks. I think they both serve purposes. I mean, I think retention is not just about the money. I think there's many, many other reasons people would should want to stay in your practice. I mean, that's just one important thing to remember. But you need to feel like they're fairly compensated. So you need to do your best, unrelated to challenging times we're having now, doing salary surveys to make sure you're competitive, and you're compensating people well. And in the near term bonuses, they can help with retention. And, you know, it's kind of what we're doing now and what we do at the end of the year annually as well, and what we do for staff. But I think they both serve purposes. I mean, I think people feel they're not well compensated, they'll potentially leave right now, especially MAs, right, or call center staff, they might, you know, go someplace else. And so I think, you know, we have found in this crazy, great resignation environment that some of the bonuses have helped as well. But, you know, bonuses at some point go away, and they're going to ask, what else you're going to do for me, right? So it's a long, long answer. But I think it, you know, it really depends. And they both can be useful. Yeah, similar question, actually, a few months ago, in our executive committee meetings, that question was asked, again, and again, should we just be giving bonuses or increase the salary? And as Rick said, both have a purpose. So increasing the salary was definitely was needed. Because when they look around, and you know, everyone, especially the staff, the MAs and the techs, they always say, okay, you know what, I'm getting this many dollars per hour more somewhere else, I don't want to leave. But you know what, it does make a difference for me. So when you increase the salary, it just tells them, okay, you know what, we are ready to step up for you. If you just stay here, it makes it does make a huge difference. And we have seen, since we have increased the salaries, our retention rate has increased tremendously, I mean, it was it did make a huge difference. On the other hand, bonuses, just is a way of appreciating them. They're hard work. And of course, I mean, I think especially with the holidays, they, all the employees expect some sort of bonuses. So yeah, I mean, both of these things have their purposes. And it depends on your financial situation, how much you can afford. But if you can, probably can do both of these things. Okay, any additional thoughts, Kim? No, I definitely do agree. I see that, you know, raising salaries has definitely helped with keeping some staff. But I do think that bonuses is definitely a plus to help retain them. So I agree. So another question just came in along the salary line. So it's somebody asking for advice. And maybe this goes back to Dr. Roman's negotiation talk. When you're under a hospital owned situation, what advice can you offer for a higher salary? So how can this person negotiate potentially a higher salary? Any tips? How can well, maybe rephrase that if you're if you're a hospital owned? So I think they work in a hospital owned situation, and they're looking to get a higher salary. So maybe they don't want to, you know, we've seen a lot of people migrate to being traveling and getting higher salaries, but it sounds like they have some loyalty to where they work. But the competition is stiff out there, right? Yeah, I mean, I think so, you know, for the employees, you know, that that is, you know, looking to leave, I mean, it's you have to kind of try and help them understand, you know, what are the other reasons they shouldn't or the reasons they shouldn't leave, right? I mean, I think it's difficult to make decisions, you shouldn't make decisions on individuals is one thing, right. And it's just, it's true that people, you know, will leave potentially for further opportunities. And, you know, we have a, you know, we're not an ownership situation, but we have a couple of JVs. And, you know, we have less control over salary changes for staff. And that's a little bit difficult, as well as more of a system decision, but maybe other thoughts, there's Sufian or Kim. You know, when I finished my training, I was I had for a brief period of time, I was in a hospital. And that's when I realized, you know, hospitals are bigger entities, they are bigger corporations. And mostly, the HR policies are that they don't make decisions based on like one division or like one, just a small group of people. So they have to go system wide. And that makes it difficult to negotiate just for one employee, or just like few employees in a GI lab to negotiate their salary, because they when they go up, they go up system wide, because that is mostly their HR policies. I mean, legally, I mean, they can get into some pitfalls if they just increase someone's salary and not other people's salary. So that is why I mean, we see these days, a lot of time, nurses just leave the hospital job go on travel, and the same hospital is ready to pay for the travel nurses, but they won't pay the same amount to their employed nurses. Because as I said, I mean, it's unfortunately the system issue. So it's a difficult situation that if you are a hospital employee, it's, it's difficult to go and negotiate with them on individual basis, it usually does not work. So another question from earlier today, have you found that physician leadership is spending so much time trying to retain hourly employees that they're overlooking management? Could the amount of managers be leaving due to not being heard? I'll give one example, then I'll turn it over to Kim and Sufjan. I mean, we did have one manager that was with our practice for many, many years, who burned out, classic burnout. And she went through the COVID cycle last year, you know, she was a senior manager for the clinics, you know, chronically short staff, you know, working and you know, working and not managing tough time hiring. And just it's just classic burnout. And she was engaged and supportive, but she basically left health care, left management and working as an executive secretary for a financial firm. That's just an example of what can happen. So managers are key. And, you know, you may overlook them because they are in their position and, and focus on kind of lower level employees. But losing a manager is really, really tough. So I think you really need to focus on your managers, make sure they're doing well. You know, touch base with them frequently, support them, and support them among the providers, right? Because they're under fire. One thing I've noticed is if things aren't going well, when you have a lot of new staff, the providers complain, who they complain to the manager. So the manager is often kind of under fire. And it's difficult, right to be hearing that. And everybody gets kind of frustrated. So they need support. And you also need to obviously talk to the providers, you know, but don't lose sight of management for sure. Along the way. Sufiyan? Yeah, I agree with that. I think the managers especially are in the toughest spot right now in practices, because they have the providers on the top just pressing for stuff to be done, and they are getting frustrated. And then they're dealing with the staff every day to take care of the things trying to fill the positions. Unfortunately, we didn't have any in upper level management, we had pretty stable, quite a bit of stability. But in mid level managers, we did have people just leave, because of the same reason they couldn't handle that, because they couldn't fill up the positions or people they would hire, they would just leave, even before they had time to just use their education and training yet. So we did have quite a bit of mid level manager, you know, roll over, go away, or just leave just because of that, or just get out of the healthcare business altogether. I mean, we had an excellent manager for one of our smaller ASEs. And she just left healthcare. I mean, she was excellent. We tried to keep her but she was just burnt out because of the same issue, trying to hire techs all the time for leaving, they cannot work. So it is a tough situation. But and as I said before, what you need is you need communication with them, they need support. Okay, so well, as a manager, yes, for a brief moment in time. I did feel that I was coming up coming up on that burnout. And yeah, it's this has been the most stressful year and a half of my career. But I found that voicing my concerns and really communicating with providers and even upper management. I'm telling them how I feel, again, with hiring and who's leaving and then retraining and it became a cycle, it became a very, very, very exhausting cycle. So I do, I do feel that communicating with the providers definitely did help. I'm still here, I'm still there. I'm hanging on, it is getting better. It's just I really hope that in the near future, the staffing situation does stabilize. It's starting to but that I think for me was the biggest part of feeling burnt out because you put on many hats, you're an endotech one day, you're the director of nursing one day, you're housekeeping one day. Um, I mean, it does make you stronger, but but it is exhausting. But I do have I feel for me, I do have a great support from providers and upper management. So so how do you all work to create and Kim, how did they work to create like a safe space for you to voice those concerns? Do we? Do we feel like sometimes some of our folks are getting burnt out because they don't feel they're they're in a safe space to voice concerns? Um, well, from from what I see, I feel like, like the endotechs secretaries, I think they're a little bit more afraid to voice their concerns. So a lot of them will go through me and I always tell them, um, you know, you're an adult, speak up professionally, explain to them how you feel, and they're receptive, they will listen. Um, I tell them if you keep pushing it off and not telling them how you feel, then you know what's going to happen, you're going to feel burnt out, and you're going to end up leaving. Um, but communicating to them is so important, because when they see what you're going through, for the most part, they take that into consideration. And they really do try to make a change and help. So, so to the physicians, how do you actively create a safe space for your employees to speak up along what Kim was saying? Are there techniques that you can do? Or how do they know it's okay to voice concerns? So, um, so I think it starts with the culture, uh, the culture of being that you're not going to get penalized, if you raise a voice or concern about something that that's where it starts. And what we did recently, that has helped us a lot is to have a process in place that everyone should know who they need to go to, if they have a problem. If they see an issue, they should be able to go and talk to this person. And that person can be, uh, will, doesn't have to just go out and say, Oh, this person was saying this is a problem. They can hide your name, go on with the problem, take it upstairs. And that has actually helped to weed out a lot of problems in the ASC and in the clinic where when people know that they will be able to just report whatever the problem is, and someone will listen to that. So, and something will be done. So that's what we have done. And that change in culture has helped us. So you created an anonymous pathway for them. Is that what I just heard you say? Yeah. So the thing is many times, you know, what happens is, and sometimes it's true and sometimes it's unfounded that, uh, the employees or, you know, the techs or the MAs, they are a little bit afraid of going to the position directly complaining about something going on. And they feel more comfortable talking to someone who is, who is around them, who is another MA or who is in charge of the clinic. Who's, who's not that up higher in the hierarchy. And if they know they have confidence that that person can take this thing upstairs somewhere else and won't, and they won't be affected by that. That has helped. So, yeah, I mean, that's what we created here, not like totally anonymous thing, but at least this way they know retribution, they won't be penalized. So that's what we agree. Yeah. Yeah. Those are, those are great ideas. Great practices. Um, you know, I think that, um, one of the keys, um, right. You need, people need, I agree with comments made people need to feel safe to bring concerns forward. There's, they're not going to be penalized or it's not going to have the negative consequences, but if nothing's done about that complaint, they're not going to complain anymore. And they might leave your practice. I mean, it has to be followed through. And so, um, we've had challenges where sometimes the staff would go to the doctors and have the, want the doctors to do something for them. You know, they may have relationships with doctors, right. Um, uh, but it really should go to the manager, right. When it's, but if it goes to the manager and nothing happens, that's a huge problem. So you're going to make sure that they feel safe, uh, bringing things forward, um, you know, whatever way that you can do that. I mean, we're hoping to have good manager employee relations so they, they can, they can do that. They can come to their manager and something can happen about that. Um, you know, it's interesting. I mean, during the height of the craziness last year, you know, our message was, we're in this together. It's teamwork. We're all in this together. And, and, and we had a lot of involvement of all the staff and trying to problem solve and, you know, and, and do things together. And actually I think that's a really beneficial thing. Um, and, and I think that will, that will actually carry forward more because the end, you know, you realize, you know, when, when times are tough, you do really rely on each other at all on all levels. And so, um, um, they need to feel like, um, they're contributing to the company, the business, uh, it's purpose-driven, um, and, and so that they're, they're making a difference, but they can also have a voice. And I think those things are really important. So am I hearing you say too, if somebody voices a concern, um, but it's not something that for whatever reason gets acted on, um, that some form of acknowledgement just so they feel like they are being heard, validate that, um, even, and, and explain why maybe it's not a practical request is, um, that's, that's a helpful towards retention as well. Absolutely. You gotta, you have to close the loop. If people put things forward and nothing happens, they'll, they'll stop making suggestions and they'll think that nobody really is, is listening. Right. Um, and that's, that's not a good place to be. So, Kim, do you feel like you've gotten anything that you couldn't implement or are people asking reasonable, making reasonable requests? Um, I find, find that they're making pretty reasonable requests. If there are certain requests that, um, obviously cannot be corrected or implemented at that moment, I, I do make sure that I follow through with them and tell them, okay, this is not something that we can definitely address or fix right now, but perhaps in the future we'll, you know, we can revisit that and try to fix that. And for the most part, for me, I see my staff is fine with that. Um, then when they have more stronger feelings about other certain things, I really try to enforce it with the providers and the upper administration staff to try to get these things fixed and explain the importance like this, but what they're looking for is not unreasonable. Um, we need to retain these people. So we have to find another way to satisfy what they're looking for. At least meet them halfway. Um, we can't give all, you know, give all of what they're looking for. And I, I feel that it does work. Um, but unfortunately you can't always make everybody happy. Um, and you just do the best with, um, what you have and then try to make it work. Makes a lot of sense. Goes back to what Dr. Chowdhury said about culture. If you're doing it in the right culture, it's really, um, so we don't have any other questions in queue, no hands raised. Do the panelists have any questions for each other? So let me just ask one more thing, um, before we, um, kind of move to closing remarks today. Um, you know, uh, ASG as a society is, is, is putting out a lot of information around, around diversity, equity, and inclusion. Um, are there any comments from your practices in terms of things that you might be doing differently along those lines as, as that has taken hold in the national conversation? And it's really, those concepts are starting to translate into practice. Um, let me just take a stab at that. Uh, we, we have a quite, uh, diverse practice. Um, if you look at the physicians, we look at our staff, uh, but you know, last year with all the things going on nationally, there was, you know, it affects everyone, but what's the conversation is. And so as, as, uh, uh, as the, the managers, uh, managing, uh, uh, you know, partners, we actually sent a letter to all of our, uh, uh, employees, all the, all the techs and the CRNAs, everyone, and just reaffirming that, you know, what we are for the diversity in our, in our practice, we want everyone to be, to feel included and feel safe in the practice. And if you have any issues and you need to, you, you come to us and we really value you here. We value every person in our practice. And people are really appreciative of that, that we, we really went to that extent that we voiced these things. So, but, but, but it, it does matter how, how the, how they perceive you. I mean, the practice might have a lot of diversity, but you have to communicate and tell them, you know, you be value each and every person, uh, no matter who you are for our practice. Yeah, I, I agree with that. And we, we, we did the same thing. And I remember thinking about this and reading some HBR articles, many, many articles about this, um, you know, how businesses should be responsible. And, uh, and we have our practice product quite as diverse, but we, you know, we had some employees that has to leave early to go to some of the protests. And last year there were a lot of those in Denver. We actually supported that. Um, and, uh, we, we also send a communication that we support diversity and this is who we feel we are culturally. So we did the same thing and, and, and yeah, it was very positively received and it's the right thing to do. I agree.

employee management

bonuses

raises

staff retention

fair compensation

diversity