Performance evaluations of physician executives. (Career Management).

The staff at the American College of Physician Executives is regularly asked for help in finding performance evaluation forms for physician executives. We don't have them and I wanted to find out if anyone did. I interviewed six senior physician executives to see how they were doing or not doing performance reviews in their organizations. There seems to be a trend toward doing them, but it is in the beginning stages.

Of the physician executives surveyed. the experience ranges from formal lengthy evaluations with rating scales to reviewing a short list of goals. Several are in the process of developing new systems or revising old ones. Probably the most useful part of a performance evaluation is the conversation between the physician executive and the person he or she reports to.

Howard Kirz in the ACPE course, Managing Physician Performance," says most physicians and physician executives are generally doing a good job. If you can stop approaching performance evaluations as passing negative judgments on people but as having a conversation to hear their concerns, learn what their goals are, and offer ways to help them achieve their potential, they can be useful, enjoyable experiences for both people. When they are just telling someone what they have done wrong, both parties are miserable and the reviewer tends to procrastinate and, in some cases, never gets around to doing the review. Most people want to hear some praise when they are on the right track and some guidance when they have strayed off a bit.

Many physicians view the physician executive's job as an unnecessary expense because he or she does not generate income the way a clinician does. Performance evaluations that clearly show what has been accomplished in the last 12 months are one way to prove that the physician executive does bring added value to the organization.

Richard Gaintner, MD, FACPE 

Chief Executive Officer

Shands HealthCare, Gainesville, Florida 

I am President and CEO of Shands HealthCare, a large academic health care system in Gainesville, Florida. Annually, I put down what my goals are for the coming year and what I've accomplished for the last year and review them with my board chair. We agree on what it was I set out to do which is really what the organization has set out to do. I don't like forms when it comes to evaluating performance. The way to measure performance is to say--this is what I'm going to accomplish, this is the timeframe, this is how much it is going to cost. At the end of the year, you measure it and you either are there or you are not there, but you have to write stuff down. I usually take two or three pages to write down the various things. I also ask each of my executives for this once a year. Financial rewards go along with it. We reward people for individual performance and for team performance. People should be rewarded for performance, not just that they showed up.

The trouble with forms is that people use the form rather than thinking of what they are really trying to do. Forms as guides are okay but the trap you get into is rating people on a scale of one to five. I find that pretty sterile.

Six senior physician executives were interviewed to see how they were doing or not doing performance reviews in their organizations. There seems to be a trend toward doing them, but it is in the beginning stages. Of the physician executives surveyed, the experience ranges from formal lengthy evaluations with rating scales to reviewing a short list of goals. Several are in the process of developing new systems or revising old ones. Probably the most useful part of a performance evaluation is the conversation between the physician executive and the person he or she reports to. If you can stop approaching performance evaluations as passing negative judgments on people, but as having a conversation to hear their concerns, learn what their goals are, and offer ways to help them achieve their potential, they can be useful, enjoyable experiences for both people.

Key Concepts: Performance Evaluations/Reviewing Performance/Feedback

William Rock, MD, MS, FACPE

Corporate Medical Director, Emeritus 

Dean Medical Center

Madison, Wisconsin 

We are a 400-person multispecialty group, owned and governed by physicians. We have 26 sites, 16 affiliated sites, and six medical directors. Our medical directors answer to the governing board of directors. All physicians in the group at large expect that medical directors must perform well if they are to be paid. When our group was formed by a merger of two smaller groups to a total of 80 physicians, I became the first medical director. Ten years ago we added a second. In the last two years we have added four more. The usual practicing physician's attitude is the board must continually verify that those medical directors are needed for the success of the group.

We medical directors meet twice a week together. We meet once a week with the CEO, and we meet quarterly with the vice president of marketing, who is particularly interested in leadership development. At these meetings, we talk about areas of interest, which include leadership, quality, credentialing, recruiting, liaison functions, etc.

We are particularly interested in the skills of medical directors. Some can be measured objectively, such as outcomes, or dollars, or hirings, etc. Some skills are of a soft quality, such as dealing with personnel issues. In the past, I have frequently attended the monthly meetings of certain departments to act as an arbitrator, to keep the meetings peaceful and productive. There have been frequent disagreements about money, turf battles, operation room schedules, hours in the office, days on call, etc. All this type of supervision is considered a soft skill and somewhat difficult to measure.

Formerly, I would simply keep a record of the activities I participated in and submit that list to the board of directors at the end of the year. Since almost every activity had been observed by some member of the board or leadership group, they could grasp my activities fairly easily. At that point, the CEO and I would sit down annually and talk about the activities. I must say, the supervision was not very intense.

At this point, we are trying to develop a better process of accountability for the medical directors. We Intend to discuss in a general fashion what activities we have engaged in, and present that summation to the board of directors quarterly. In the meantime, we will continue our dialogue among our directors with the CEO, and hope to keep everybody moving in an accountable, effective fashion for proper leadership.

Morris Feitel, MD, FAAP, CPE, FACPE

Senior Vice President, Medical Affairs

Meridian Health System

Brick and Point Pleasant Hospitals

Brick, New Jersey

I'm in a three-hospital system with three medical directors. We use different evaluation systems in each of the hospitals, and each of us is evaluated by our own hospital executive. Mine is a community, acute care, 300-bed hospital.

The CEO used to take the job description and evaluate each point on a yearly basis. It was two to three pages long. Two different CEOs and I did not like it, so we changed the system. Now at the start of every year, we write our goals for the year. We list eight to 20 bullets. At the end of the year, you evaluate how you have succeeded in reaching your goals and you fill out a similar form. The CEO reviews both those forms and gives you essentially a type of grade, which determines your bonus. Then the CEO has a discussion with you that lasts from half an hour to an hour. There are four vice presidents and he does them all in the same day. The VPs like it and the CEO feels under much less pressure than the old prose way of evaluating the full job description.

Examples of two of my goals: We recently set a goal to partner with our specialists rather than push primary care development. Like everybody else, we were pushing primary care development in the acquisition of practices, and we started to lose too much money. When we started partnering with the specialists, we brought the surgeons in and explained to them that we wanted to work with them as part of the team. We wanted to give them early starting times in the morning, increase the efficiency of the operating room so that there was a shorter turn around time, give them Saturday operating time if they could use it, give them block time--a certain time every Thursday to do four or five cases. If they would use it, they could keep it.

We wanted to convince the surgeons, in general, that we were out to help them, and we would do as much for them as a competing surgery center would. We had a three-month evaluation and we are pleased to say we have increased our total surgery by 20 percent in the first quarter of the year. The surgeons are happy and we are very happy. That was a goal for me as a medical director.

One of my other goals for this year is to encourage the OB department to decrease their C-section rate and right now they are not very gung ho about it. They think there has been too much push on this and that ACOG (the American College of Obstetricians and Gynecologists) has not actually supported this as much as they would have liked to see them support it. We had to get a little tougher with them. One of the things I did was that I brought the chairman of our professional care committee, who is an attorney, to one of the OB departmental meetings and had him explain what the role of the board was In quality assurance and how the board does get involved in seeing that the physicians are meeting the goals we are trying to achieve. That was very effective.

I've been here 10 years. With the old job description way, every year you got the same evaluation. It didn't serve the purpose, where as this is kept current because you are putting down what you intend to do that year differently from what you did the previous year.

Mark Doyne, MD, FACPE

Vice President. Medical Affairs

Curative Health Services 

Richardson, Texas 

We are a disease management company that manages centers that treat chronic non-healing wounds, such as diabetic ulcers, venous stasis ulcers, and pressure ulcers. In our typical center we might see 500 to 600 new patients a year. We'll see about 65,000 in the system in 1999.

Each center has healing achievement goals. We have good data systems to determine what percentage of the chronic wounds we heal and in what period of time. Some are in the high 80s, some are in the high 70s, so we have specific, objective clinical outcomes. Typically, we will have a relationship with a hospital or a health care system. We have our clinical pathways on the Internet that are password protected and serve as Interactive teaching tools. We are In 35 states and are about to reach into Guam. I deal with more than 150 medical directors, each of whom has anywhere from four to 16 physicians under his or her jurisdiction--150 different hospitals, none of which are my employees. I can't personally get out and do an annual assessment on every medical director.

We are developing a system. As for measuring qualities like leadership, I would like to make it as objective as possible in terms of their ability to build a team, add physicians, retain physicians, resolve conflict, get physicians to comply with established clinical pathways, make sure that Dr. X does not continue to arrive 45 minutes late and that he or she is willing to correct the situation.

If you are the medical director you are also a treating clinician, so we will find out how well your patients like you as a physician. We can also get feedback from physicians you are supposed to be directing or leading and from the rest of the administrative team around you. It's cycling in my mind. We are coming out with a very detailed, elaborate physician orientation manual and a lot of the content will be in there.

Brendon Kearney, FRACP, FRACMA, FACPE

Chief Executive Officer

Royal Adelaide Hospital 

Adelaide, Australia

I am CEO of a health service institution, which is a teaching hospital, but we have several other services Including a state-wide mental health service and community services. We don't tend to spend perhaps as much time as we should evaluating our own individual performance. We have a core of five executives--two physician executives, a director of nursing, a director of resources, and a director of corporate strategy and planning.

We usually go away for a day or two at the beginning of each year. The five us will sit down and debate the issues and try to list those that are of significance and priority for the service in the context of the overall health services strategic plan. We just go outside the hospital and concentrate on that. I'll write that up after we have had one or two days of discussion. It's quite a comprehensive plan that can cover a huge range of topics--maybe 15 to 20 topics we think are the priority issues for the service. Six months later, we evaluate how we are doing. We all have job descriptions, but we don't find it is very useful evaluating against those descriptions. That's because there is a standard format in our system in Australia. It's not functional enough to evaluate.

Compensation is not tied to it. The revenue or income in Australia is set by general industry standards. There is really not individual bargaining outside of that--it's happening in a few places, but it is very rare. The only thing that is tied to it is that most of us are on three to five year contracts, The board uses that information to assess whether we are reap-pointed or not.

We are thinking about a more formal system of performance appraisal. We haven't implemented that yet, but we are looking at everything from a fairly structured system that is quite detailed to a voluntary appraisal system. I expect we will end up coming down somewhere toward the latter--that is a voluntary approach where the executives will complete that each year and present that and go through the interviews. I'll have to do the same with my chairman of the board. It's fairly informal at the moment because we are still debating what is the most useful thing to do. We sought the help of consultants, but I think, particularly in the physician executive area, it is very difficult to come up with criteria to measure their performance.

Donald Hofreuter, MD, CPE, FACPE

Administrator/Chief Executive Officer

The Wheeling Hospital

Wheeling, West Virginia 

We use a modification of a standard job description with evaluation on a scale of one to five. The form is about five pages long. It's a part of a very detailed job description, which is defined specifically for that job. The evaluator goes over the form with the involved individual, and then they jointly set the goals for the next year. Incremental increases, over the cost of living adjustment, are based on the job performance.

When we first started the typical one to five rating, people were very gracious in their grading systems, but then we had a session on how they needed to be graded and we are getting a much more objective evaluation. We took Out the "warm and fuzzies" and made them much more defined for the particular job. We assumed that everybody did quality work, etc. A physician executive is handled in the same way as any other senior administrator. An example of an item on the evaluation form: Meeting with department managers on weekly basis and participating in active listening. We wanted this to be objective. If they didn't meet weekly, how many times did they meet and what kind of participatory interaction took place?

Conclusion

Whether or not your organization has formal performance reviews for physician executives, you will do your job better if you have some specific plans written down. It doesn't matter what you call them--plans, goals, objectives--but you need to write them down, measure them. Sometimes it is a quantitative measure in that you brought in this much money or reduced length of stay by this percentage. Sometimes it is less measurable--I kept two physicians from killing each other: reduced the yelling in a meeting. Ideally, you would talk this over with a boss who encourages you, occasionally praises you, and offers suggestions for how to do some things better.

If you don't have a boss that does that, cultivate a friend you can talk to at least every six months at the Fall and Spring Institutes or every couple of months on the phone. One of the perks of ACPE membership is that members serve as a support system--they listen, advise, and encourage each other. A friend can give you some feedback about your performance as you compare notes about what each of you is doing.

I also suggest that you try to persuade the person to whom you report to sit with you every six to 12 months and review your accomplishments and agree on what each of you wants to happen in the next timeframe. In these days of decreased job security, you shouldn't go for long periods of time without finding out if you are pleasing your boss.

Barbara J. Linney, MA, is the Director of Career Development at the American College of Physician Executives in Tampa, Florida and a member of its faculty. She can be reached at 800/562-8088. If you have a performance evaluation process for physician executives that you are pleased with and would be willing to describe, please call Barbara Linney at 800/562-8088 or email her at [e-mail]

Note: All interviews were conducted May, 1998.