CEO Apgar: A Look at Recruiting and Retaining Rural Hospital CEOs in North Dakota
By Stacy Kusler on
After two years of research, a study exploring the factors related to recruitment and retention of rural hospital CEOs in North Dakota has been completed.
The CEO Community Apgar Questionnaire (CEO CAQ) identifies unique challenges and opportunities faced by rural Critical Access Hospitals (CAHs) in attracting and retaining top leaders. By examining 50 different factors – ranging from the perception of the community and housing availability to the relationship with the board of directors and salary and benefits – the study equips participating communities with tools and resources to address their identified challenges. Ultimately, the questionnaire's results will help communities improve their strategies and practices to attract and keep CEOs in their rural hospitals.
Taking a Pulse
The term "Apgar" is likely familiar to those in the healthcare field as an assessment used with newborn babies on Appearance, Pulse, Grimace, Activity, and Respiration. The Apgar score for newborns is given at one minute of life, and again at five minutes of life. Like the assessment of newborns, the CAQ assesses recruitment and retention factors in year one of the study, and again with the same questions 12 months later. This allows the community's progress to be tracked over time and offers a real-time assessment of a rural community's assets and capabilities in recruitment and retention.
workforce specialist at the UND Center
for Rural Health.
The CEO CAQ is the sixth iteration of the larger Community Apgar Project. The original CAQ began in 2007 at the Family Medicine Residency in Idaho, under the leadership of Dr. David Schmitz (who in 2016 joined the University of North Dakota (UND) School of Medicine & Health Sciences as professor and chair of the Department of Family and Community Medicine), and Dr. Edward Baker, director of and professor in the Center for Health Policy in the Boise State University School of Public and Population Health.
Starting in Idaho, the initial project was developed and
tested to find new ways to help different rural Idaho
communities recruit and retain family medicine
physicians. After Idaho, Wyoming joined as a
participating state, followed by North Dakota in 2010.
Since then, 13 states, plus Australia, have participated
in the CAQ in one or more of its six variations.
The first three variations of the CAQ studied recruitment and retention factors related to family physicians in rural hospitals, rural health clinics, and community health centers. A subsequent iteration of the research project, piloted in North Dakota and Montana, assessed the factors that contributed to a good training environment for health profession students. North Dakota is the first state to implement the CEO CAQ and in 2025 will also implement an updated version of the Nursing CAQ, which will assess factors surrounding recruiting and retaining registered nurses to CAH communities.
How Does It Help Communities?
The Community Apgar project helps communities take a systematic approach regarding their job openings, and how they go about recruiting.
Communities that participated in the CEO CAQ project were given a detailed report showing a confidential comparison of their community to the state mean of respondents from the study. Each community offered two respondents – the CEO as well as a member of the board of directors who would be involved in CEO recruitment. The same questions were asked of each respondent, and answers were combined to create a singular response from that community. Dr. Baker, a veteran research analyst, translated the responses into what is now called the Community Apgar score. Scores were reported to communities individually – what did they collectively think were the challenges and opportunities about themselves? And comparatively – how did they compare to what is generally being experienced by all 24 communities who participated in the study?
From these results, rural communities were able to see what factors they excelled in, and which factors were more challenging to them compared to their peers. Overall statewide advantages and challenges were also learned in the process. The participating North Dakota communities agreed that having good schools and having a good relationship with the board of directors ranked highly as factors contributing to positive recruitment and retention of CEOs. Factors that were more challenging included access to housing in the local community, as well as spousal or significant other satisfaction.
Recruiting for Retention
What if a community didn't
participate in the Apgar project and still wants to
improve their recruitment and retention practices? To
help all rural communities to maximize their efforts,
3RNET (the Rural
Recruitment and Retention Network) partnered with the
project in 2016 for the first iterations of the CAQ. Mark
Barclay, director of member services for 3RNET, created
the "factors to market your rural community" booklets,
which defines each factor, explains why it might be a
challenge, and offers solutions on how to address the
factor. 3RNET even created an annual webinar series, the
3RNET Recruitment
for Retention Academy, taking sections of the
"factors" booklets and training rural recruitment
professionals on how to address each factor.
Rural recruiting can be a guessing game. What's going to get someone to take an interest in a particular rural community?
"Rural recruiting can be a guessing game," says Mike Shimmens, executive director of 3RNET. "What's going to get someone to take an interest in a particular rural community? Furthermore, what kind of candidate is the rural community actually looking for? The CAQ allows communities to move away from just looking for a warm body, to being laser-focused on the type of provider or person that would fit the needs of their community."
Dr. Schmitz, who is also the co-creator of the Apgar project, and partner on the North Dakota Community Apgar efforts, is passionate about the difference this project can, and has, made in rural communities.
"The Community Apgar project helps communities take a systematic approach regarding their job openings, and how they go about recruiting," he says. "It helps them shape questions like 'Might this be the best fit for a new grad, or for someone with more experience or later in their professional career? If so, what are the different financial incentives that may attract the potential candidates? Is this a job where perhaps there would be advantages for a physician or professional with kids who are still in grade school? If so, how could flexible work hours and our great local schools set this job apart from others?'"
Ultimately, Schmitz says, the Apgar project "really helps find answers to questions like that, and it challenges communities to change their thinking from 'we just want someone' to 'we're recruiting for retention and long-term happiness.'"
The CEO Apgar results will be presented at the annual National Rural Health Association Conference in May, as well as at the Dakota Conference on Rural and Public Health in Bismarck, North Dakota in June.
is the connection between rural healthcare facilities in North Dakota and qualified health professional job seekers. As the workforce specialist, she assists rural facilities to attract medical providers and other health professionals to their communities by sharing job opportunities. Through her position, Stacy is working to reduce the healthcare workforce shortages throughout the state.
