By Wendy Opsahl
The Apgar score for newborn babies is a rather novel concept if you think about it. This fast, simple physical assessment immediately following childbirth and repeated at five and ten minutes thereafter determines if babies are ready to meet the world without additional medical assistance.
Take the Apgar score and change the players. What if there was a similar test for hospitals – quick and repeated with intervention measures on standby — to assess readiness for recruiting physicians? That is precisely what Dave Schmitz, M.D., a family physician from Boise, Idaho, wondered, when he took a new job as associate director of rural family medicine at the Family Medicine Residency of Idaho. After years of observing Idaho communities struggle with recruiting health providers, in one case paying over $20,000 to an external consultant who left the facility with an ineffective opinion report and lack of action steps, Schmitz envisioned something new. Something based on quantifiable data. Something that incorporated the whole community. Something that shows people on graphs and charts where they are and how to achieve their goals.
Enter Ed Baker, PhD, director of the Center for Health Policy at Boise State University. Schmitz brings experience from the trenches, Baker brings the research know-how, and together they’ve developed the Community Apgar Questionnaire (CAQ), an innovative, evidence-based way for health care facilities to see how they stack up in the eyes of the health care providers they are recruiting.
The Community Apgar Questionnaire got its start in 2007, when Baker and Schmitz received funding from the Idaho Office of Rural Health and Primary Care to develop a tool that identifies and weighs factors important to communities in recruiting and retaining rural family physicians. The 50-factor CAQ contains questions about geography, economics, scope of practice, medical support, and hospital and community support. It is typically administered at a hospital, where Schmitz acts as a physician interviewing for a job. He meets with administrators, physicians and staff, and also gets to know the community in the way that a visiting physician would typically do – perhaps meeting principals, real estate agents and pastors, among others. The responses are recorded, the results are analyzed, and a return visit is made to present scores to hospital leadership, board members and key community decision makers. This program is funded by the Idaho Office of Rural Health and Primary Care for use in each critical access hospital in Idaho over the next four years, but is also ready for use beyond state lines.
“The evidence is a way for communities to see themselves the way a physician might, and it opens productive discussions,” said Schmitz. “Hospitals are learning, for example, that sometimes offering a favorable on-call schedule is more important than a large salary. They also see where they stand compared to peer facilities, for example, getting a feel for where their salary offerings rank against others.”
But the CAQ doesn’t end there. Baker and Schmitz “differentially diagnose” modifiable factors for strategic planning in each hospital. In other words, not only do they identify what hospitals are doing right, but they identify areas for improvement and help to address gaps and priorities. So, if a community has a fantastic school system and is home to parks and recreational activities, those are highlights to feature for physicians with young children. But if the physician would be on-call every evening and weekend (an unattractive option), Baker and Schmitz help communities explore solutions such as on-call sharing.
“Hospitals learn what their selling points are,” said Baker. “But this tool also gives hospitals directions to apply their limited resources strategically to make improvements. If they have only $5 to spend on recruitment efforts, we can show them where to spend that $5 most effectively.”
Baker and Schmitz return 12 months after the first assessment and complete another CAQ, followed by another return visit and presentation. This time, they also measure how well the community achieved its goals.
As a physician who’s practiced in rural Idaho, I had an inkling of what might be important,” said Schmitz, “but as researchers, we wanted to be able to develop these parameters that are evidence-based, that are reliable, so that if you make decisions to improve the recruitability of your community, then you can be confident that this instrument shows you how you look relative to your peers, and where you can have the biggest bang for the buck.”
Craig Johnson is the CEO of Boundary Community Hospital in Bonners Ferry, Idaho, population 2,600, where Baker and Schmitz presented the results of Boundary’s Community Apgar Questionnaire earlier this year.
“It was an eye-opener for a few of our board members about what things are important to physicians – suddenly they had it quantified in front of them,” said Johnson. “We have a physician who wants to bring on a partner this fall, and he is utilizing the CAQ results to figure out how to attract someone to his practice.”
The eye-opening experience is not uncommon, according to Schmitz. There are certain things that physicians look for, and it’s not always about money. “Sometimes people haven’t considered the possibility of on-call structure, recreational opportunities, hospital equipment, electronic medical records, board support, or spousal employment.”
The CAQ is a new approach to the old problem of physician recruiting. Schmitz said Idaho hospitals have tried everything from hiring recruiters to working with his residency program to create rotation experiences in their communities. While Baker and Schmitz have only done their assessments in rural facilities, they are confident the process can transfer to urban environments as well. They also have begun the development of CAQ tools for Community Health Centers and the nursing workforce.
Ted Epperly, M.D., president of the American Academy of Family Physicians, is one of Idaho’s leaders in medical education and a vocal supporter of the Community Apgar Questionnaire project.
“Understanding the dynamics that go into physician recruitment and retention is critical to the primary care workforce needs of America,” says Epperly, director and CEO of Idaho’s Family Medicine Residency program. “This endeavor could become a Rosetta stone of understanding and unlocking the critical factors that not only draw but keep family physicians in some of the most underserved parts of America.”