Recently, I was called into a primary care practice that was in crisis. “My employees are about to revolt,” the senior physician told me. Staff members were pitted against one another, work was piling up, and no one was accountable for getting the job done.
It didn’t take long to conclude that the root of the problem was that staff members’ roles were ill-defined. They didn’t know what was expected of them, and they felt underappreciated. Because of this, it was easy for them to make excuses or point fingers when something didn’t go right.
I helped them put a plan in place to evaluate the workload for each position and create performance standards that were both realistic and measurable. This provided a greater understanding of job expectations and promoted accountability. Within a few months, the practice was humming and working as a team. Productivity and efficiency were markedly improved.
It’s all about performance
You can do the same thing in your practice. An essential part of developing a powerful work team is assessing each employee’s contribution to the organization. What you expect from your employees and what you actually get can be worlds apart. How you blend the two is the basis for achieving a well-oiled, top-performing practice.
But how do you measure your staff’s performance and know whether you’re expecting too little or too much from your employees? This can be accomplished by developing performance standards that will improve both your efficiency and accountability. You can achieve an additional benefit by using the written standards as part of your performance evaluation system. This will give you objective measurements that reduce the chance of employee discontent or even lawsuits, which are often fueled by subjective evaluations and perceived bias.
The challenge of developing meaningful performance standards begins with open communication, commitment by the physicians and support from the staff. This will ensure you do not get derailed or succumb to individual interests that can compromise the outcome.
Pick a point person
Begin the process of implementing performance standards by picking a project manager. This individual will be the point person who sees the project through to its timely completion. The practice manager might seem like an obvious choice for this role, but there are two factors to consider before you decide.
First, will you compromise the manager’s ability to manage his or her remaining workload? This is a major consideration. It’s likely that the manager’s plate is already full. Adding a major project to that load might tip the scale, unless someone else can help with other administrative responsibilities.
Second, can he or she maintain the objectivity and commitment essential to achieve the desired outcome? This is not a criticism of managers, but they tend to work closely with individual staff members and might have difficulty being objective. This process requires a careful examination of how things are done, why they are done that way, and whether they make sense.
If your practice manager is too busy or too involved with your staff to maintain objectivity, you might opt to hire a practice management consultant or human relations specialist to lead the project. Or, in a larger practice, there may be a human resources manager who has the skills and interest to take on such a project.
Additionally, a larger practice may opt to appoint a cross-position committee to work with the project manager and share the workload. They would meet with the project manager at predetermined intervals to report their progress and provide feedback.
Outline the project
Next, develop a work plan and prepare a time line to ensure that the project isn’t abandoned when something unexpected occurs. A sample time line can be downloaded below.
Kick off the project with an all-staff meeting and announce what is about to be undertaken, why the decision has been made and what advantages it will bring to the practice. Explain the objectives in a clear and positive way that helps staff understand how they will benefit. For example, you might want to inform staff that written performance standards will ensure that job expectations for each position are realistic. In addition, such standards will give management and staff the ability to identify what help is needed when work demands increase. Staff can relate to this concept, and so can management.
The more you involve staff members and ask their opinion, the more likely you are to obtain the necessary support required to succeed with implementing new concepts or changing the ways things are done.
At your kick-off meeting, inform staff of the project’s five major steps. These steps should coincide with items listed on the master project time line. They are:
Prepare a job description questionnaire describing the current job tasks and major responsibilities for each position.
Meet with individuals holding each position to obtain input and provide feedback.
Observe daily work and measure work flow.
Develop performance standards.
Implement the standards.
Steps 1–3: What do you really do?
Give each staff member a job description questionnaire and ask them to describe their work processes. Have them separate their primary tasks from those that are incidental. Their current job description can serve as a guideline, but it is important for them to describe what they actually do each day and how much time is spent on their tasks.
This serves three purposes. First, it will help you update their job description so that it accurately defines what they do. If job descriptions are more than one year old, the job responsibilities and tasks probably have changed. Let your employees know how important their input is in updating the job description and developing realistic standards for their position.
Second, it will help defend your practice and the decisions made regarding individual employee performance. The importance of valid job descriptions cannot be overestimated. Recent employment laws are not written in favor of the employer. The written job description defines what you expect of an individual employee and serves as a tool to hold them accountable. Job descriptions are vital whether you have one employee or 20.
Third, the completed job description questionnaire will clarify which tasks consume most of the employee’s time and the significance of the various tasks. This will enable you to identify areas of duplication and determine if processes can be refined or eliminated. The information you garner will be invaluable when you are preparing the performance standards.
When you give the job description questionnaire to employees, ask them to complete it and offer to answer any questions they may have. Give them a deadline for completion. Schedule a time to meet with each of the employees within a few days of the established deadline so they’re not tempted to put the questionnaire aside. Employees with identical positions can decide who will meet with you as the position spokesperson. Regardless of who is selected, all employees in a position should be required to complete a questionnaire so you can look for variations in what they write and their perception of the position.
This first meeting with each employee is powerful and sets the stage for both cooperation and expectations. Involving the employees is critical. During the meeting, you will want to clarify major tasks they have described. This will help you understand what is involved in the tasks and will minimize the potential for misinterpretation.
Alongside the employee, compare the job description questionnaire to the existing written job description. Agree on what should be included in the updated job description.
Before you take this information and develop performance standards, validate the information and eliminate inconsistencies or variations in how things are done. This may require observing employees as they perform their daily tasks and comparing this to what they have written on the questionnaire. This helps clarify what tasks are essential for the position. For shared tasks, identify one employee who will be primarily responsible for their completion.
At this point, you should have more information and a clearer perspective of each position and each employee’s contribution to the greater good.
JOB DESCRIPTION QUESTIONNAIRE
Developed by Judy Capko. Copyright © 2005 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. "Get Better Results With Staff Performance Standards." Capko J. Family Practice Management. October 2005:40-44; https://www.aafp.org/fpm/20051000/40getb.html.
Step 4: Setting the standards
Next, begin the process of working with individual staff members to identify the most logical performance standards for their position. The standards should stem from the primary tasks listed on the revised job description.
Seek standards that will reflect and uphold the practice’s mission and culture while serving the primary needs of patients. For example, if your practice prides itself on putting the patient first, then a standard that requires the receptionist to greet each patient within 30 seconds of arrival would reflect your commitment to patient service. Similarly, you could require nurses to introduce themselves to new patients and welcome them to the practice.
A standard is only reasonable if it can be quantified. For example, a standard asking your employees to “treat each patient with respect” would be too general. However, specifically asking employees to greet patients within 30 seconds of arrival at least 95 percent of the time can be measured.
Determining the quality expectation for a particular standard can b e complicated. For example, the medical records clerk may have a standard that requires her to pull the charts for the next day and attach a charge ticket by 3 p.m. Must she prepare 100 percent of the next day’s charts, or is 97 percent acceptable, assuming 3 percent of the charts cannot be located? It’s up to you and the employee to work this out.
You’ll also need to consider the quantity of work involved. For instance, you cannot hold the clerk accountable for pulling all the next day’s charts until you know the average number of charts required to prepare for the next day. This can be determined easily by reviewing past schedules and identifying the average number of patients scheduled per day. This quantifier is critical in holding staff accountable. In addition, as the practice grows, it will help you identify when an individual’s workload has grown and additional staffing is needed.
Once you’ve reached agreement on reasonable expectations, you can draft the written standards.
Step 5: Implementation
When you’re ready to implement your practice’s new standards, hold another all-staff meeting. Employees should receive a copy of their standards and revised job description at this time. Another copy should be placed in their human resources file. Explain how these standards will be used as an objective tool for:
Hiring the most qualified candidates,
Training new employees,
Promoting existing staff,
Conducting unbiased performance evaluations,
Recognizing and rewarding performance,
Identifying when staff needs more help.
Thank everyone for their contributions and support, and invite them to meet with you if they have additional questions.
To keep the new standards from being simply an organizational exercise, your managers need to be familiar with them and use them to accomplish the above-mentioned tasks.
Setting the bar
As you set employee standards, look at how you evaluate each physician’s performance as well. Physician productivity and performance are traditionally evaluated by the numbers. Month-end reports tally patient visits and new patient referrals, and monthly charge, receipt and adjustment patterns are reviewed and compared. Physician performance is also monitored by looking at coding patterns.
These are excellent standards for comparing tangible productivity and financial performance. But these standards do not reflect the practice’s vision and culture. They do not evaluate your commitment to staff and patients. They do not examine clinical outcomes. These vital areas of performance should not be overlooked.
Ask yourself if you are willing to hold physicians to the same standards – timeliness, patient service and workload volume – to which you hold staff. Often, employees will observe the attitude and performance of their leaders and reflect that example. By setting high but realistic standards for physicians and staff and holding everyone accountable, you can enjoy the benefits of a high-performing practice.