Performance Reviews That Actually Work

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Dear Director: It’s a new year and although I’ve been in my chairman job several years, I’ve never done any kind of evaluation on the docs in my group. I give them annual bonuses but have started to wonder if they need more feedback. Do chairman typically do annual evaluations on their docs?

There’s no doubt we are achievement focused as a society. Starting with report cards as kids, we’re conditioned to receive near constant feedback about our performance. As such, annual work reviews have become a regular part of the fabric of industry – formalized decades ago through the Performance Rating Act of 1950, which mandated the annual review of federal workers.

That said, it doesn’t surprise me that you don’t perform annual evaluations. You’re not alone. In a very unscientific poll I conducted at ACEP in 2013, 30% of people reported not having any sort of annual evaluation. Of those who had them, 75% had them annually while the rest were divided between quarterly and semi-annually. Only a few reported monthly meetings on performance. In my first eight years after residency I only had one annual evaluation completed, despite working in the same hospital with the same chairman the whole time. During that evaluation I was only downgraded on my handwriting, which admittedly is horrendous. As a result, through the years, I’ve truly embraced typing into EMRs and using scribes.


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When I became a chairman, my new facility required evaluations and I was left to my own devices to design one. Over the past couple of years, there’s been increasing talk about the value (or lack of value) of formalized annual reviews – and even if they should be eliminated. I was surprised –
and slightly concerned – when one of my favorite authors, Stanford professor Robert Sutton – appeared in a New York Times article to be against evaluations. Digging a little deeper it became clear that Sutton is against bad evaluations that don’t have purpose or usefulness and on that score I’d have to agree.

So the big question is this: What should the company (or the employee) be getting from an annual review? For GE CEO Jack Welch, evaluations help to “rank and yank” employees, rewarding top performers (the top 20%) and firing the bottom dwellers (the bottom 10%). Meanwhile, software giant Adobe recently abolished annual evaluations in favor of what they call a “check-in,” which starts at the beginning of the year, occurs throughout the year, and is used to set and manage expectations. Adobe has created a softer, more user friendly evaluation method, while still managing expectations and providing feedback. Certainly, many emergency medicine groups (and hospitals) feel that the evaluation is critical so people know where they stand in a rank order system. Evaluations also create paper trails to justify promotions and raises or performance improvement plans and terminations.

What they should achieve
Evaluations need to be more than a director and employee reluctantly meeting for a few minutes to check a box. And they should certainly never be left in a doc’s mailbox for the doc to review, sign, and return. In the end, evaluations need to promote and encourage career development. In order to reach that, there are critical components that need to be covered. The employee should be able to walk away with direct feedback regarding their performance and the evaluation tool should help establish goals and ultimately improve performance. Everyone has strengths and weaknesses. The performance evaluation should recognize someone’s strengths and encourage them to utilize these skills, but it also should identify opportunities for improvement. Discussion should occur about how to improve. While most of us sandwich any negative issues between two positive traits, there does need to be discussion about both strengths and weaknesses. However, evaluations shouldn’t just be the manager talking to the employee. If evaluations are going to be an effective tool to manage performance, they should be both collaborative and continual throughout the year. This means that besides the formal paper trail, there should be ongoing, informal conversations where managers give feedback on performance regularly throughout the year. This is what Adobe was getting at when they “eliminated” the annual evaluation. However, there is value in having the formal HR paper trail that the evaluation creates. Most commonly, this is used to protect the company in court for not doing something equitable, but it also insures that the employee gets treated equitably when it comes to salary increases.


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Making them easy
The best performance evaluations have clear and measurable objectives. We work in a metrics industry and it’s pretty easy to design evaluations that are metrics based—patients/hour, rvu’s/hour, length of stay, etc…Metrics should include a baseline level of performance and then can include banding strips that outline (and perhaps align raises) above average and excellent performance. Our environment also necessitates that we evaluate teamwork and leadership – which honestly can be much more difficult. These can include showing up on time to shifts, attending committee and staff meetings, participation in projects, and maintaining low levels of patient complaints. Although a paper evaluation may only occur once a year, remember it’s important for the ED director to have ongoing discussions with their providers throughout the year that provide meaningful feedback and coaching and are also documented. And the end of the year evaluation needs to be in-sync with the feedback that was provided throughout the year. I had a friend who was due to be nominated for partnership once his first year evaluation was complete. The problem came when his evaluation didn’t meet the minimal requirements for partnership. Talk about a faux pas. An entire year’s worth of planning and looking into the future shot down because the metrics where never discussed. Our employees are entitled to not be shocked by their annual review. That means that as a manager, you can’t just be everyone’s cheerleader; you’ve got to have the tough conversations.

How often should reviews take place?
I used to work in an ED where bonuses were paid quarterly. These were metric based, primarily on productivity, and I simply plugged (reliable) data into a matrix to calculate the bonus. Because there was significant money at stake, I felt it was imperative to sit down with every provider quarterly and review performance. This also led to coaching, which led to underperformers improving and making more money. This led to easier conversations for me. Although time consuming (and at least one doc, who did well, told me he always felt like he was a middle schooler being called into the principal’s office) it was a pretty effective way to improve our department. According to an article in the Harvard Business Review, Millennials in particular (those born between 1977-1997) want feedback. However, Millenials also come from an “everybody wins” generation which is not consistent with the rank order performance evaluation. In the end, your physicians probably want mentoring and coaching, so your best course is an honest, well-constructed annual performance evaluation.

Avoiding pitfalls
Hopefully by using a well-designed evaluation tool and having frequent discussions with providers throughout the year, the evaluations go smoothly. But there are still some tricks to avoid getting into a sticky situation. I’ve seen a case of an inaccurate review—in this case, a falsely glowing review on a below average performer—hamper efforts to develop the necessary paper trail to remove a physician. This was probably a consequence of a lack of preparation, a poorly designed tool, and a failure to acquire the necessary information by the evaluator. The stakes are high if you get the review wrong in either direction – good people might get irked and leave and bad people may be hard to remove later. The manager needs to spend the time to be prepared (data, information for review) prior to the meeting, should have rehearsed the message that is being delivered, and then find the appropriate time for the meeting (a 5 minute break in the middle of the shift or before a shift is not the right time).

Self evaluations
I recently completed my own self-evaluation. I’ve had to do this every year I’ve been a chairman and while I’m sure I suffer from some grade inflation regarding my own value and skills, I do find it an interesting and worthwhile experience, particularly when I need to write in goals for the upcoming year. My self evaluation is sent to my chief medical officer who then adds in his own opinions of my performance (sometimes he agrees with my self-assessment, sometimes not) and this is used to generate a discussion between the two of us about the department’s prior year success and our future goals. Although I don’t have my own staff do it, many companies have employees review themselves. Like any evaluation, the end result is only as good as the tool and the time/energy that the participants put into it. Ultimately, getting some component of a self-evaluation into the process is a good way to engage the employee in thinking about their performance.


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I work in a pretty transparent company. Everyone knows where he or she stands in a rank and order system. Yet I’m not a believer in the bottom 10% rule, because if you’re performing well, there’s no reason to lose your job. Fortunately, I can’t remember the last doc who left our group because they failed to meet the goals, though I did have someone resign years ago after I announced goals for the department for the upcoming year. This doc felt they’d never be able to meet them and didn’t want to give it a try. Each year, I try to be proactive by discussing our department goals at a staff meeting. Our evaluations go beyond objective measures and include topics like citizenship and teamwork and I start laying those expectations during the recruitment process We’re pretty transparent so most metrics are just a click away for my docs. For those who may have trouble reaching a goal, I meet with them to discuss strategies. I then trend performance and provide feedback. Currently, I sit down with each individual at my site formally at least annually, though it could be as frequently as every month or two if necessary. Hopefully, no one is surprised by the data at the end of the year when they see their evaluation. If you’re meeting your goals, you should feel good about your job security and the evaluation should be an affirmation of the good work that you’re doing as well as include a discussion about future goals. Evaluations also protect the employee to make sure the pay is fair and equitable. I would encourage you to complete an annual evaluation on each provider. Spend the time necessary to develop a good evaluation tool but don’t forget that it’s as important to have regular conversations with providers throughout the year about performance.

 

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

4 Comments

  1. Must be nice to eval yourself! You can support or admonish your ED staff. Maintaining a positive work force and thus workplace environment is paramount to staff & department morale. If the admin crew chooses to go on the attack and take down physicians then I implore any EM physician to start tomorrow in finding a new job. We’re all accomplished, well meaning, well educated adults. Let’s start by treating each other like we’re instructed by non-clinical hospital admins and paid consultants (btw- perhaps the biggest fraud in medicine today). No one needs a “coach”. That’s more politically correct “fluff”. Physicians need to regain the high ground and work to support each other. Certainly, not to admonish or tear down each other. We’re our own worst enemies….or at least when we allow physician admin turncoats to dictate policy.

  2. Annual evaluations are extremely important and should be bidirectional. When I offer guidance and feedback to EPs it relates to two primary goals: (1) doing what is best for the patient and (2) doing what it takes to create and sustain a professionally satisfying environment. I use metrics that related to the universal triumvirate of EP excellence – smart, nice and fast. ‘Smart’ means safe care along with judicious utilization. ‘Nice’ means pleasing to patients and nurses. ‘Fast’ is calculated by workload units per hour. These metrics come from a system I helped developed, which includes feedback from 25% of our discharged patients contacted via email/text — see http://media.standardregister.com/standard-register/docs/Healthcare/Urgent-Matters-Innovation-Award-_announcement_FINAL-2.pdf.

  3. When I was ED chair I felt that one question asked of every NURSE in the ED about every doc in the ED would likely give me the insight I needed to dig deeper. Just like anesthesiologists are the go-to source to recommend a surgeon, the ED nurse who works with a dozen or more docs knows their relative strengths and weaknesses. The question: If you needed emergency care, would you feel comfortable being cared for by Dr. X? (Yes/No/No comment). The results would rarely surprise anyone. Unfortunately, this approach never was tried due to fears of retribution on the part of the ED nursing staff – perhaps an indicator of the importance of the question.

  4. DIRECTORS SHOULD BE EVALUATED BY THEIR SUBORDINATES. IT SHOULD BE A TWO WAY STREET.

    METRICS AND CHART REVIEW, IN WHICH THE REVIEWER AND REVIEWEE ARE ANONYMOUS TO EACH OTHER IS A GREAT WAY TO GO.

    HAVING NURSES AND MIDLEVELS EVALUATE DOCTORS IS INAPPROPRIATE. PUTTING DEROGATORY INFORMATION IN A PROVIDERS RECORD FROM THOSE WHO DO NOT HAVE THE EXPERTISE TO RENDER SUCH OPINIONS IS UNWISE, AND PUTS THOSE WHO USE THIS TECHNIQUE AT LEGAL RISK.

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