Three Groups at Boeing Zero in on Performance Measurement (published by National Productivity Review, Spring 1994)

The Blossoming of Melissa (published by Roots and Wings Adoption Magazine, Jan/Feb/Mar 1996)

Learning to Walk the Leadership Talk? (published by Healthcare Executive Mar/Apr 1994)

Using Leadership Criteria to Measure and Reward Performance (published by Physician Executive, Aug 1995)

Practice what you Preach (published by Best Practice, "Measuring Performance" Issue, IFS International Lmt, UK)

Integrating Processes and Performance: Benchmarks and Keys to Quality (published by Performance & Instruction, Sept 1993)

...and 19 more

Using Leadership Criteria to Measure and Reward Performance   

(by JT Carr, published Physician Executive (peer reviewed) Vol 21 #8 Aug 1995)

Abstract:  Physicians speak of performance and outcomes. They speak of customers and patients. While many leaders nod their heads, shake hands in agreement, and establish liaisons, agreements are implemented without an appropriate understanding of how to recognize and measure leadership performance. How are physicians and other management team members measured? Are you measuring the right things? Physician executives should be measured for simplicity, for streamlining, for standardization, and for knowing the right processes. That's productivity. They should be measured for taking risks, for being creative, and for exploring and initiating new ways to use existing resources. That's entrepreneurship. And they should be measured for kindness, for empathy, for building trust, for sharing with colleagues, and for working together. That's teamwork.

        Today's health care system demands leaders who are measured and rewarded on productivity, entrepreneurship and teamwork. While physicians and other members of the health care management team speak of reform and cutting costs, they often do not demonstrate the leadership skills that encourage and promote these actions. To "walk the talk", physician executives must evaluate and reward their performance in terms of these leadership criteria. Physician leaders might ask themselves: "How well do I measure up?"

Ask Your Customers

      Physician executives interested in determining and improving their performance should ask their customers to rate their performance in terms of productivity, entrepreneurship and teamwork and to recommend how they can improve. Knowing that many people are "customers"-- staff, colleagues, patients, suppliers, and others--physician executives should ask each of them to rate their performance to help focus on customers' specific needs, which should then become the physician executives' goals.

      "When MDs think of quality, it tends to be on the technical level, and less on the service level. We've matured now to looking at physician performance in terms of how [physicians] are caring for patients," according to Cavanaugh. "Patient satisfaction--achieved by a team to meet the needs of the ultimate customer, the patient--is a part of the physician's evaluation."1

   Ask Patients. If you want to know how well you are performing, ask your patient-customer. "A patient-satisfaction survey is a powerful reflection of care. Patients can tell how their own health was over a period of time."1

   Ask Colleagues, Suppliers, Staff. "Physicians need to hear not only what the customer says but also what their fellow worker says."1 Cavanaugh's organization uses physician review surveys on peers, nursing administration, pharmacy, hospital utilization, and ancillary utilization.

   As more physician executives realize that reform means looking more critically at their own performance, things may become uncomfortable at first. As you examine performance in terms of productivity, entrepreneurship, and teamwork, be gentle with each other, for mistakes will be made. Changing behavior is difficult. The key is providing the right rewards for the right behavior.

   Ask Yourself: "What do colleagues say about my performance? How well have I met my customers needs? Are their needs reflected in my goals?"

Measure and Reward Simplicity

    A major part of productivity is simplicity.  Most quality experts have never practiced in health care. If they had, they would realize that many methods and tools are too complicated and take too much time and effort for real-life applications. If simplicity were rewarded, executives might better understand that quality is everybody's job and should not be relegated to a specific department. Quality means productivity. Productivity means simplicity.

   People, especially middle and upper management and non -practitioner experts, will continue to make these methods complicated unless they are rewarded for simplifying them. Complexity may have something to do with arrogance and power rather than leadership. Some daily activities executives can undertake to enhance simplicity include the following:

   - Simplify the process.

   Most everything we do is a process. Simplify processes so that people can understand them. Processes already exist and do not need to be reinvented or re-engineered. Physician leaders simply need to be refreshed in learning the steps of the process, in realizing how they are integrated, and in teaching and rewarding themselves (and others) for using them correctly.

   - Write with simplicity.

   Executives who succeed in creating simpler, more clearly written, less wordy regulations, policies and documents will be the leaders who guide the management ranks. And shouldn't staff and managers leaders be rewarded for this simplicity?

    "There is a difference between acknowledging the inherent complexity of a problem and then making it more complex than it has to be by loading up the group that has to solve it with theoreticians, academics, and consultants," says Friedman. "Most of the people who have worked in outcomes study never have treated a patient...are not practitioners. As a result, things got much more complicated than they needed to be", she says.2 

    Quality is offering something of value to the customer. Frequently it is something as simple as a kind word, a smile, a touch, or a personal visit. When that kindness is put in writing, that is another, perhaps more recognizable, measure of quality. 

    - Simplify when you standardize methods. 

    Whether one deals with software development, manufacturing, or health care services, management functions--such as planning, designing, and documenting--can and should be standardized and made easy. Quality improvement approaches such as TQM, or international standards such as ISO 9000, are guidelines for management. If planning is done correctly, these approaches should be relatively similar.

    Simplify and standardize management practices such as planning, designing, and documenting, and keep the documents simple, clearly written, and readily available. Reward people for following them.

    Process : The planning process

   Measure: Standards, written and illustrated clearly, simply. 

    Sample Reward: Time off 

    - Simplify the rewards. 

    Rewards can include such simple things as fun, personal growth, time off, praise, recognition, freedom, and a piece of the action. Laughter and humor help lessen stress and tension. Relaxation through fun with "stupid" things frequently provides real world solutions.

     Process: The creativity process

    Measure: A simple event that produces relaxation, ideas

    Sample Reward: Fun

      Performance can be measured by using plans, standards, tests, and reviews to measure productivity; an implemented idea or solution to measure entrepreneurship; and some commitment or agreement to measure teamwork. These criteria include functions that have standard processes whose result can be used as a measure of quality.

    Ask Yourself: "Do I understand that planning, writing, and designing are separate management processes whose steps can be standardized? Do I streamline work? Do I reward simplicity?"

Measure and Reward Entrepreneurship

    Creativity often occurs from having limited resources, yet being responsible to perform and being rewarded for the right results. Creativity and innovation are great steps forward, but they occur only when physician leaders drive fear out of the workplace and have patience with mistakes. In order for creativity to occur, relaxation and fun are required. Some daily activities executives can undertake to enhance their entrepreneurship include:

   - Reward [Praise] risk takers.

   Frequently, risk takers have to break the rules, do something risky, and demand change.These changes require compassion and caring rather than technology and complexity. Risk taker-leaders listen, make judgments that may not be popular, and have the courage to carry their decisions through.

   - Reward innovation.

   We learn through trial and error. Trial and error are at the heart of entrepreneurship, where ideas are tested using prototypes, changes are made, and mistakes and failures are opportunities to modify and try again. Being rewarded for using a systematic process ensures that tests catch mistakes. Reward results and decisiveness more than effort. Be innovative with rewards as well as technology.

   Process: The creativity process

   Measure: Trial and error that results in an implemented idea

   Sample Reward: Praise

   Ask Yourself: "Am I a risk taker? Do I admit mistakes and learn from them? Do I praise my efforts, whether successes or failures? Do I reward myself with [for example] personal growth for learning something new?"

Measure and Reward Teamwork

   Physician leaders must themselves treat all people-- staff, colleagues, suppliers, patients, and all others with whom they come in contact-- with respect and dignity each and every day. Teamwork means working together for a common goal, assessing each other's performance, modeling trust and humility. Teamwork also means strong listening skills, empathy, and cooperation. The "best indicators" of care, says Cavanaugh are when physicians "show respect and courtesy".1 Some daily activities physician executives can undertake to enhance their teamwork include:

   - Show respect for one another.

    Showing respect is the basis of dignity and kindness. Trust, dignity, and self-esteem are affected by how we talk to and treat one another.

   Rusk recounts his personal crisis, hurt and achievement.3 Taunting and teasing were common in his household. He was surly, resentful and angry, yet he was hungry for kindness and understanding. The key lay in his realization that he was not being treated with respect at home and, even more importantly, that he was not acting as respectful at home as he was at the office. He was not earning the respect he desired from his family. He decided that, if he was as loving and respectful to his family as he wanted them to be to him, he could demand that respect from them.

   In New Orleans, a surgeon was ordered to pay a nurse $5,000 for shooting a surgical staple into her buttocks as she stooped to count sponges on an operating room floor. Lola Simpson was less interested in the award than in bringing the doctor to task for the 1990 incident. The doctor had just finished stapling the hip of a boy being prepped for surgery when the nurse bent down to count sponges. The doctor turned the stapling gun on her. "There was a nice muscular man standing next to him in the operating room, but he didn't think to do that to him", the nurse said.4

   - Learn "influencing" skills and avoid barriers.

   Maintain people's dignity by what you say and how you say it.  Many physician executives talk at colleagues and patients rather than with them. Instead of listening by paraphrasing or reflecting feelings, some executives respond in ways that close off communications. Some of these hindering ways include belittling ("That's silly"), lecturing ("The reason you feel this way is..."), evaluating ("What a terrible thing to do"), or giving solutions ("This is what you have to do about it"). The net effect of these barriers is disrespect and anger. Patients, staff, and colleagues stop talking to you about issues when such barriers occur.

    As reform continues, so do changes. Hutchens speaks of "problems of autonomy and control...turfdom battles are common".5  Turfdom battles occur when people are rewarded on a win/lose basis instead oif a win/win basis. Instead, executives should applaud efforts, cheer successes, work together, and be rewarded individually for contributions to and accomplishments by the team.

    Process: The negotiating process

    Measure: An agreement resulting from working together

    Sample Reward: Personal growth

    Ask yourself:  "Am I modeling kindness and compassion? Am I respectful in my words and behavior? Am I successful at influencing others? Do I praise myself for results achieved working together?"

Summary 

     Physician executives should measure and reward their own performance based on productivity, entrepreneurship, and teamwork.  Rewarding productivity and simplicity would reduce costs, tension, weariness, frustration, and mistakes. If productivity rather than complexity were rewarded, systems and procedures would be simplified. Reward the right things, and keep rewards simple.

    Performance: Focus on productivity 

    Sample measure: Words and documents that exemplify simplicity

    Sample reward:  Praise

    Reward entrepreneurship and risk taking. Humor and relaxation promote creativity and innovation. Executives, colleagues, staff, and other customers must get to know each other and allow trust to develop so that new ideas will be received with respect.

    Performance: Focus on entrepreneurship

    Sample measure: Performance that exemplifies creativity 

    Sample reward: Fun, prizes

    Reward teamwork. Teamwork and trust are enhanced by getting acquainted and having fun together. If win-win rather than win-lose were the outcome, "game playing" would be eliminated and working together would occur. Rewarding teamwork would decrease judgments and promote greater understanding. Discrimination would be eliminated if performance were based (rewarded) on results achieved by working together with other health care executives.

    Performance: Focus on teamwork

    Sample measure:  Agreements and behavior than exemplify respect

    Sample reward: Praise, fun, prizes 

    Whether the physician executive is a caregiver, a corporate executive, or a patient, productivity, entrepreneurship, and teamwork are tightly integrated. When executives decide to free themselves from the complexity of paperwork and reward themselves and colleagues for simplicity, things will get simpler. When physician executives reward themselves and their customers with fun and relaxation, creative ideas will be forthcoming. When executives treat themselves and colleagues with respect and kindness, and reward themselves for building trust, teamwork will mean caring. And caring is helping customers. What will be the result (outcome)? Performance will improve. Customers will be happier. Goals will be met.

    Ask yourself: "Am I ready to assess my own performance? How well do I measure up?"  ##

References

 1. Robert Cavanaugh, MD, "Performance Evaluation: Personal and Professional," #46 audiotape, 1993 MGMA Conference, Seattle, WA 

 2. Emily Friedman, "The Social Implications of America's Healthcare System",#69-112 audiotape, 1993 MGMA Conference, Seattle, WA

 3. Tom Rusk, MD,"In Crisis Lies the Seed of Change", Audiotape, Hay House, Carson, Calif, 1987.

4.  "Briefly", complied from JA Wire Services, Eastside Journal American, Feb 8, 1994, pA9

5. G. Michael Hutchens, "Future for Clinic Management", #140 audiotape, 1993 MGMA Conference, Seattle, WA