Finding an incentive plan that actually works.

Incentive systems are all the rage in academic medical centers these days, driven by the need to maximize and direct faculty effort. (1,2) However, many well-intentioned plans fail because the system rewards an intermediate goal while hoping for completion of the activity, or rewards one activity while hoping for a different activity altogether. (3)

During a recent change in our department's administration, we felt it was important to assess the effectiveness of our department's incentive plan. We developed and administered an anonymous Likert-type survey to assess the level of faculty satisfaction with and impact of the incentive plan.

The results showed that, based on their experience in fiscal year 2002:

* 80 percent of our faculty did not understand how the amount of their incentive was determined

* 40 percent felt the incentive plan did not play a role in increasing their productivity

* Only 35 percent could agree that they were highly satisfied with the current incentive plan

So we set out to create a more effective reward system by combining motivational theory, the experience of other departments, and our own departmental needs.

A review of the literature revealed that the majority of departments appeared to be using a straightforward value-based approach. The value-based or points plan is a system in which every departmental activity is assigned a value.

When it is time to pay out incentives, individual faculty member's points are divided by the total number of points obtained during that period to determine their proportion of the incentive. This type of plan is easily understood and is particularly helpful if there are system deficiencies that need to be addressed.

We presented this to our department as a model to emulate. After much discussion, the faculty rejected a value-based approach, as the majority felt it would change the culture of our department from focusing on the team to focusing on the individual.

Specifically, the value-based approach changes the faculty focus from how they can advance the departmental mission to how they can earn points. (3) It is a zero sum system, meaning if you get more points, the relative value of mine goes down. So there is actually an incentive to not help others.

A goal-setting model

Our faculty specifically asked for an incentive plan with a goal-based approach and accepted the fact that, while it is more ambiguous than a values-based approach, it was most consistent with the current philosophy and culture of our department.

However, the chairman felt it necessary to incorporate a mechanism to track the productivity of the individual faculty members. Also, about this time, the dean of the medical center mandated that all departments develop a system to track the productivity of their faculty.

The compromise reached was that 50 percent of the incentive plan would be goal-based, and the other 50 percent would be at the discretion of the chair based on performance standards that were established and monitored.

Due to its multifaceted approach, the plan was named the Motivation/Incentive/Professional Evaluation (MIPE) plan.

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At the next annual evaluation, the chair met with each clinical faculty member to determine their goals and the methods of attaining them. Recognizing that many faculty had not formally set goals in the past, we developed a goal template to aid them in designing goals. We also provided measurement criteria to bring to their discussion with the chair.

One of the most difficult steps was to ensure the resources necessary for goal achievement were available. In our department, the biggest resource was time. The chair and each faculty member negotiated an appropriate match of goals and resources, and determined measurement criteria.

Finally, ongoing follow-up for feedback and evaluation was provided through the annual faculty evaluations. However, we stressed with our faculty that it is important to address problems early rather than wait until the end of the year.

The development of the professional productivity evaluation portion required multiple steps. The most demanding part of this task was to formalize the system of data collection and analysis. Data are being gathered and organized on a Microsoft Access database.

Multiple discussions were required between the faculty and the chair as some faculty members were uncomfortable with the concept of data being collected on their productivity. The activities have not been assigned specific values, but the chair reviewed the performance of each faculty member when assigning incentives.

When a faculty member appears to be deficient in a certain area, the chair addresses this with him or her. This area is then incorporated into a goal for the next year, or a reduction in incentive if the discrepancy persists.

To minimize faculty complaints of extra work and to promote honesty, the vast majority of data are not collected by the faculty themselves but by a project specialist.

Our original plan called for incentives to be given once a year; but early in the first year our chair realized that a year is too long to wait for incentives and he gave additional incentive payments four months into the fiscal year.

These payments were based on productivity as measured by clinical activity, with some consideration for research, teaching and administrative efforts. The year-end incentive still reflected goals attained.

During the course of the first year of implementation when 50 percent of incentives were to be based on goal achievement, it became clear that this approach was very demanding because:

* The achievement of goals set without very specific metrics could not be accurately delivered

* Goals might be of different levels, and consequently easier to achieve for some and less so for others (so equity was not clear)

* In an academic anesthesia department that experienced an unprecedented increase in operating room case numbers, less time was available to achieve academic goals than had been anticipated.

The motivator-hygiene model

Because the goal-based incentives were regarded as de-motivating, the chair, after discussion, decided to uncouple specific goal achievements from incentive payments.

In motivational lingo, the hygiene needs (those built-in desires to avoid pain) were separated from the growth or motivational factors. How did we do that?

First, we addressed the hygiene needs. Incentive payments were determined on clinical productivity (measured as American Society of Anesthesiologists' time units--specific units for every 15 minutes of billed operating room time--adjusted for clinical time in non-income-generating clinical activity) and a comprehensive annual review of academic (teaching, research, scholarship), service (departmental, institutional, national), and team-work contributions.

In so doing, the annual incentive payment was weighted 60 percent for clinical activities and 40 percent for activities in other areas. Work conditions, like the call schedule, were addressed by organizing faculty work teams to develop and implement an equitable and efficient call strategy. Departmental policies were clarified and made easily available on the intranet.

The goals were then regarded as a means to focus and motivate faculty, rather than a reward system. A mentoring process was established to provide the faculty with support and direction. A mentorship oversight group, comprised of the chair and four full professors, was established.

The younger faculty members are encouraged to partner with a more senior faculty member to use that person as a sounding board for concerns and an alternative mechanism for feedback regarding their goals.

The oversight group reviews the progress of faculty in tandem with the departmental promotion and tenure committee. This provides faculty members with the best opportunity for growth, achievement, recognition and advancement.

As we implemented the motivator-hygiene model, we realized that the true answer to the motivation question is not found in only one model of motivation. Any motivational plan needs to address the expectations of the faculty and be equitable.

References

1. Griner PF, Blumenthal D. "New bottles for vintage wines: the changing management of the medical school faculty." Academic Medicine 1998; 73:720-724.

2. Jones RF, Gold JS. "The present and future of appointment, tenure, and compensation policies for medical school clinical faculty." Academic Medicine 2001; 76:993-1004.

3. Lawler III EE. Motivation in Work Organizations. San Francisco, Calif; Jossey-Bass Publishers, 1994.

By Ronald D. Kratz, MD, MHA and Berend Mets, MB, ChB, PhD

Ronald D. Kratz, MD, MHA is an assistant professor of anesthesiology at Hershey Medical Center in Hershey, Pa. He can be reached at 717-531-6733 or [e-mail]

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Berend Mets, MB, ChB, PhD is the Eric A. Walker Professor and chair of anesthesiology at Penn State Milton S. Hershey Medical Center/Penn State College of Medicine in Hershey, Pa. He may be reached at 717-531-6597 or [e-mail].