End point measures are critical components for any learning and training strategy. Listen to Fred Fishback, President and CEO of Javelin Learning Solutions, talk about key end point measures that not only measure, but impact, real, behavioral change.

Engagement Measures: 2:02
Learning Acquisition Measures: 3:50
Continuous Training Measures: 7:18



This is a multi-part series on fostering an effective physician remediation and skill-building strategy. The strategy can be applied to all healthcare workers who struggle in certain aspects of their jobs. Leaders from all backgrounds can use it to their advantage.

Consider this statistic: 74% of healthcare employees in hospitals report they have seen doctors engage in disruptive, unprofessional behaviors.

There is no denying that healthcare work is tough. It is a blend of strong personalities and business, technical, ethical, and emotional pressures. Sometimes good employees take a bad turn. Sometimes they are ineffective from the start. Sometimes the job or people-environment changes, and employees are simply ill-prepared. And while it is easy to start the probation cycle and simply go through the steps, it much harder to transform the employee and improve the situation. In this part, we focus on changing the narrative surrounding remediation—moving it from process to relationship, from discipline to benefit.

The cost of remediation is substantially lower than the cost of turnover.

According to the AMA, the cost of turnover for a single physician ranges from $500,000 to $1,000,000. Others put the average cost of turnover between $400,000 and $600,000 or even higher. Lost revenue, recruitment costs, and signing bonuses add up to substantial dollars.

‘…the cost of turnover for a single physician ranges from $500,000 to $1,000,000, depending on the specialty.’

Keep those figures in mind: they are what follow when remediation efforts fail. It’s also worth noting that there is no guarantee the physician’s replacement will be tangibly better. (After all, you were confident in your initial hire, and it still didn’t work out the way you intended).

This is where remediation comes in. Given the success rate of remediation strategies and the uncertainty of new hires, allocating a modest sum to remediate struggling physicians is an extraordinarily-wise investment. Coalition research puts the successful turnaround of physicians undergoing remediation at 75%. Our statistics peg it similarly at 80%, although we focus primarily on professionalism and interpersonal issues, not medical or technical.  Surveys from resident physicians show variable remediation success rates, ranging from 49% for professionalism problems to 89% for medical knowledge deficiencies. All signs point to the fact that, when done well, remediation can and does have a good chance of working.

The typical spend on remediation ranges from $10,000 to $25,000—a far cry from the $500,000 to $1,000,000 for a single turnover. While outcomes are not guaranteed, if it works in three of four cases, you can cover a good many remediations for the price of a single turnover. The long-term financial return on an organization’s remediation investment is enormous.

Remediation is not a punishment but a benefit.

Compare the cost of turnover to that of a successful remediation effort. Now, think of remediation like a health club membership or a wellness benefit. It is designed to greatly reduce your long-term health spend by making positive lifestyle changes, especially for those currently making unhealthy choices.

Unfortunately, the word “remediation” has some baggage. Due to the negative connotations involved, some people believe a person on remediation is well on their way to leaving the organization.

Probation. Documentation. Progressive discipline. Termination. And let’s not forget the whispers in the hallways. Seldom is remediation viewed as a benefit—but we can change that narrative. We can illustrate that remediation is an effective strategy for helping people through a rough patch. We can remind people that there is no shame in struggling.

In our experience, we have found that remediation requires surprisingly small changes, implemented consistently. You might think of remediation as a targeted growth spurt. It is not uncommon for doctors to grow and mature asymmetrically in their skillset. Knowledge often exceeds application, and technical competence may override interpersonal prowess. There are times when empathy may outpace leadership. 

And again, this is where remediation comes in. It is designed to rebalance the physician’s efforts and promote a greater symmetry of skills, all while recognizing their exceptional talent in specific areas. Since we don’t want a shortcoming to supersede the physician’s talent, remediation can help the individual leverage their talent, readjust their skills, and make small behavioral changes that will transform their work efforts.

Some of those small behavioral changes might fall upon the physician, while others might be the responsibility of the leader or team. One thing is certain, however: success is built on small, positive behaviors that accumulate over time.

‘You might think of remediation as a targeted growth spurt. It is not uncommon for doctors to grow and mature asymmetrically in their skillset.’

Remediation is a relationship rather than a process.

Before we continue exploring the benefits of remediation, let’s go over some contextual information.

95% of remediation cases are referrals from leadership. 5% are self-referrals.

These are the first statistics that need to change.

When we chat with an employee after a leadership referral, 90% know they need to make some sort of change. Only 10% are unaware.

These statistics speak volumes about our culture and our failure to proactively help those who struggle in their jobs.

‘…success is built on small, positive behaviors that accumulate over time.’

Any mediocre leader can take good employees and make them better. Real leadership inspires and transforms employees who are not rising up to expectations.

It’s easy to get frustrated. It’s easy to think the struggling physician is taking up valuable space—space that would be better filled by a different recruit. We have all heard clichés like: “cut your losses,” “you can’t save everyone,” and ”he’s a lost cause.

It’s easy to start the disciplinary cycle, offer some coaching, and follow the approved process. Most of us know the drill. We know all about listing out the grievances in specific terms, noting the required changes, and then spelling out the potential consequences. From there, it’s document, document, document. The stronger the documentation, the better the organization’s position when it comes time to terminate. This represents a technical, almost legalistic approach to remediation that is far more threatening than encouraging.

‘Any mediocre leader can take good employees and make them better. Real leadership inspires and transforms employees who are not rising up to expectations.’

Yet, documentation is not the center of remediation—it is an adjunct. The center of remediation is your relationship with the employee, your journey and joint efforts in fashioning a future of productive behaviors. Focus on building that alongside the physician. It goes beyond being a mentor or coach, and into being a true advocate. Great partnerships are crucial to great leadership.

Leaders can change their outlook to change the outcome.

The moment we label an employee, we adjust our behavior towards that person. We start to focus on the behaviors that support what we already think, and we overlook what doesn’t fit. Psychologists call this “selective attention.” The phrase indicates that our beliefs determine what we see.

Inherently, this is an unfair approach. It keeps us from being objective. What else might be going on to enable the employee’s unacceptable behaviors? Moreover, how do we know that the employee’s failures are not—at least partly—linked to the manager or even the system at large?

Put simply, the surest way to have a problem employee is to label them as such. Reputations spread. When we have a problem with someone, we let others know, infecting them and perpetuating the issue.

To counteract this, we must assume positive intent. Now, this does not mean we should excuse bad behavior—quite the opposite. Rather, it means we must uphold an underlying belief in the worth of that person. Most people want to do good work and be an accepted member of the team. Positive changes to the relationship will transform all parties’ behavior for the better.

‘…documentation is not the center of remediation—it is an adjunct. The center of remediation is your relationship with the employee, your journey and joint efforts in fashioning a future of productive behaviors.’

And ultimately, remediation can pivot on how you define the relationship. You can view yourself as a boss trying to manage a broken employee, or you can see yourself as one-half of a productive partnership meant to benefit everyone involved. At the end of the day, your culture is directly proportional to the quality of your relationships.

Leaders are defined by the challenges they overcome.

Some of the most amazing employees in my career have gone through rough patches, passed through immaturity, and made poor choices. I have watched a number of so-called “problem employees” become role models and champions of important initiatives. Some of them have even risen to the highest ranks of the organization. They often look back on their mistakes and the remediation that followed, and they view the experience as a positive career turning point.

‘…your culture is directly proportional to the quality of your relationships.’

Why? An intolerance of employee mistakes is a surefire way to spread mediocrity. “Worst to first” is a probable, not possible outcome. “Turnarounds” will likely become your most loyal, dedicated employees—and many will go on to share their stories of triumph as coaches, mentors, and advocates.

Who doesn’t love a rags-to-riches story? Inspiration is all about overcoming the odds. In this way, remediation is an ideal setup for another inspirational story that will, over time, create a virtuous cycle of success and foster a culture that cherishes its employees.

As a leader, you are defined by the challenges you confront. Remediation of a struggling employee is one of those difficult challenges every leader will face again and again. Your real worth as a leader is rooted in what you do, not in what you achieve. Consistently do the right thing and the outcomes will take care of themselves.

In the next part, we will begin moving through the remediation process, starting with the initial conversation. Far too often, this conversation is delayed and fails to get the process off to a positive start—but this doesn’t have to be the case.

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HCA West Florida (Brandon Regional Hospital) and HCA East Florida (d/b/a Aventura hospital) partnered with Javelin Learning Solutions to implement an innovate, online based remediation program designed to 1) create self-awareness in the resident to recognize their behavioral shortcomings, 2) make definitive and positive behavioral changes in conjunction with the third party coach and the resident’s faculty mentor, and 3) ensure that behavioral changes are manifested on the job on a sustained basis.

Struggling residents are ubiquitous in graduate medical education (GME) programs and requires intensive, organized, and directed efforts to remediate. Left unaddressed, resident interpersonal problems can create a toxicity in the work environment that can not only adversely affect patient care but negatively impact your culture of learning, cooperation and engagement. Although GME programs are responsible for ensuring competency in all six ACGME competencies and that residents identified as having deficiencies should be remediated, residency programs often struggle with providing effective remediation for those who fail to meet expectations in professionalism and interpersonal & communication skills. Remediation is resource-intensive, requiring individual mentoring by faculty, increased supervision, development of an individualized development plan, support through additional learning materials, and associated, formal evaluations. It’s not unreasonable for a small number of struggling residents to consume an inordinate amount of faculty time. 

From April until November of 2017, residents struggling in their interpersonal & communication and professionalism competencies were enrolled in an eight-week remediation program. The program includes a diagnostic stage to identify and describe problem behavior, developing a behaviorally based development plan that both residency staff and resident agree to, implementing the plan utilizing video simulations and video coaching, and documentation and final evaluations of the resident. 

The following steps were conducted for each struggling resident:


Gather and use data from multiple unique sources to identify and describe problem behavior. 

Individualized Development Plan

The residency staff and the resident agree to time lines and specific, behavioral measures to be met as documented in an individualized development plan.

Video Simulations

The resident completes simulations, by creating video responses, both as an observer and then as a fully immersed participant in the simulation.  The participant is allowed to reflect on his/her responses and then receives specific behavioral feedback on what was done well and what could have been done better. 

Feedback & Coaching

Third party coaches meet weekly with the resident to debrief simulation performance and discuss on the job activities

The range of problems included defensiveness, mistreatment of nurses, poor interprofessional teamwork, arrogance, ineffective communication, allegations of harassment, workplace outbursts, lack of empathy, failure to take accountability, and integrity concerns. Of the 11 enrolled in the remediation program, 2 have failed to complete. Both resident and program leadership reactions to this ongoing process have been uniformly favorable. Program leadership is recognizing significant behavioral improvement on the job. This suggests that the skills learned through the simulations and coaching are transferring to successful change on the job.

The United States needs more physicians, especially well-rounded physicians with both technical and interpersonal competence. Residency is a critical time in a physician’s career. Bad habits can be corrected early or, if not adequately addressed, can persist for decades. Interpersonal skills and professionalism play a critical role patient experience, safety, and interprofessional collaboration. According to research, they are also the most difficult competencies to change. The aforementioned remediation process provides a framework, structure, and process to successfully change physician behavior. By the time a person enters a residency program, there has been a major investment in his or her professional preparation. The time, money and effort invested is substantial and continues throughout the residency program. A formal remediation process for struggling residents is necessary to ensure we’ve done everything we can to make every resident successful, while still recognizing that not every resident should move on to unsupervised practice

Our team of coaches and behavioral scientists have been working with Brandon Regional Hospital’s Internal Medicine Residency program for about two years now. 

Watch the following video to learn about how Dr. Yvonne Braver has taken advantage of Javelin’s expertise in remediating her struggling resident physicians.

To learn more about our services, visit our website at www.javelinlearningsolutions.com or contact us via email by clicking here.

Award-winning, asynchronous video simulation learning platform 

We are so pleased to announce that Javelin Learning Solutions was named a Top 10 HRMS Solutions Providers for 2017 by HR Tech Outlook

Our team offers an innovative learning platform that features on-demand video simulations, individualized feedback, and coaching, all done asynchronously through any internet connected device, 24/7. Our unique approach to behavioral modification and skills training/coaching is the first of its kind! Our research pilots in healthcare and higher education continue to show great for the process and system.

Explore our rich array of learning solutions for the individual all the way to integrated enterprise solutions at www.javelinlearningsolutions.com to learn more!

It was a pleasure attending the 2017 Academic Internal Medicine Week at the Baltimore Convention Center in Baltimore, MD. Our interpersonal skills video simulation program was a hit with Program Directors, Chief Residents, and other exhibitors at the conference! For more information about our company and programs, please visit us at www.javelinlearningsolutions.com.

The patient was refusing all treatment. Diagnosed with Guillain-Barre syndrome, he was completely paralyzed from the neck down. In the hospital, he was depressed and had stopped communicating with his caregivers. In a desperate attempt to reach him, his medical team sent out a consult to a psychiatrist. She then did something nobody else on the team had done: she directly asked how he felt about the care he was receiving. The patient immediately responded with an angry outburst detailing how he had been disrespected throughout his treatment. Thus began a productive engagement that transformed the patient experience and led to a positive therapeutic outcome.

Good medicine, now more than ever, relies upon a physician’s ability to connect with his or her patient in a real and dynamic way. “Soft skills” – a combination of interpersonal abilities and emotional intelligence – lie at the heart of a successful doctor-patient relationship. In order to provide excellent care to patients, doctors need more than clinical knowledge and technical skills. A growing body of research is showing that soft skills such as communication, empathy, and teamwork are necessary for producing the most positive patient outcomes.

Soft Skills Promote Patient Satisfaction

Patient satisfaction has become an increasingly key issue for healthcare providers and hospital leaders alike. A major driving force for this is the release of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a patient satisfaction survey required for all US hospitals by the Centers for Medicare and Medicaid Services (CMS). The survey scores patient satisfaction as a basis for which to reward hospitals or withhold financial reimbursement. Research reveals that patient satisfaction hinges on doctors’ ability to establish a good rapport with patients, particularly during direct contact with one another. The medical interview between a doctor and a patient often sets the tone for the rest of their therapeutic alliance. When doctors communicate well with their patients during the medical interview – when patients are encouraged to ask questions and participate in their own care – the result is an increase in patient satisfaction. In addition, patients who like or trust their doctors not only report a higher satisfaction with their medical care overall, they also disclose more detailed information about their medical condition.

On the flip side, greater patient dissatisfaction can be gauged by measures such as the number of malpractice claims filed against physicians. One JAMA study showed that physicians who received 2 or more lifetime malpractice claims communicated significantly less with patients than physicians who had never received a malpractice claim. Doctors who communicated less tended to have shorter patient visit times and used less statements of facilitation (i.e. informing patients about what to expect and the flow of a visit), less solicitation of patients’ opinions, and less checking of patients’ understanding. Moreover, the “claim” physicians tended to use humor less often than the “no-claim” physicians. As many in the medical community are learning, interpersonal skills are essential to patient satisfaction and result in a thriving doctor-patient relationship.

Soft Skills Lead to Better Health

For doctors, what is even more compelling about soft skills is that they are linked to tangible improvement in their patients’ health. When patients are treated by physicians with greater levels of empathy, studies have demonstrated decreases in illness severity and duration and reductions in acute complications. Doctors with soft skills are able to have this effect due to several reasons, such as patients’ inclination to share important medical information, patient compliance with treatment plans, and patient understanding of what’s happening. Furthermore, the benefits of soft skills extend to patients’ motivation to take control of their own health. A 2011 study on diabetic patients confirmed that the patients of doctors who had high empathy scores had better control of their hemoglobin A1c as well as LDL-C levels. These indicators show an increase in patients’ willingness to participate in their own health – a goal that all doctors strive for in their work.

Don’t Overlook Inter-Professional Skills

While it is tempting to focus on improving relations with patients as the top priority, building effectiveness in inter-professional interactions should not take a back seat. Good or poor patient experience and outcomes may very well find their root cause in good or poor inter-professional relations. For example, a study of emergency room outcomes concluded that 8 of 12 deaths and 5 of 8 major permanent impairments could have been prevented if appropriate teamwork actions had been taken. A 2016 study found that focusing on team building helps to create a dynamic that produces better results, including fewer emergency room visits, fewer readmissions, and lower mortality. Physicians’ inter-professional abilities are very much linked to a safer, happier, and more efficient workplace.

Need for Soft Skills in Healthcare Today

Communication, empathy, and team leadership are some of the key factors needed in healthcare today. Data show that strong medical knowledge and good clinical ability can be augmented by superior interpersonal skills. Doctors and healthcare leaders are actively working to improve the levels of soft skill proficiency in medicine everywhere. The Accreditation Council for Graduate Medical Education (ACGME) now requires that medical residents obtain competencies such as Interpersonal Skills, Communication, Professionalism, and Patient Care. These criteria are now a requirement for completing residency training and obtaining medical licensure. In addition, the Medical College Admission Test (MCAT) has been revised to include a new section which involves the behavioral, social, and psychological elements of healthcare. A path to better outcomes and patient experience can be traced by how much attention physicians pay to cultivating these “soft” yet crucial skills.

The ACGME Annual Education Conference is where many of the leading graduate medical education practitioners showcase their findings and research. Needless to say, we were thrilled to be invited to showcase our research study titled “Strengthening Interpersonal Skills and Knowledge of US Medical Culture through Formative Assessment, Micro-learning, and feedback in International Medical Graduates” 

A special thanks to Dr. Salman Muddassir (Oak Hill Hospital), Dr. Nikolay Mitzov (Oak Hill Hospital), and Dr. Yvonne Braver (Brandon Regional Hospital) for their insights and contributions to this innovative approach to training foreign medical graduates on key interpersonal skills. 

On Fred Fishback, CEO, and Hyder Abadin, Senior Consultant, were invited to speak about our most recent work with improving the interpersonal skills of resident physicians trainees. The radio program, “Health Connections“, a is sponsored by Oak Hill Hospital, a HCA West Florida Hospital. Also in the studio was Dr. Monicka Felix, a current trainee in our interpersonal skills program.  The interview took place on 12/22/2016 at WWJB 1450AM in Brooksville, FL.

Listen to it here.




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