How Does Your Boss Evaluate You? Productivity and More

Dr. Susan Rogers (not her real name) undergoes a formal annual evaluation at the large East Coast children's hospital where she works as a physician. Every June, she sits down with her supervisor and the chair of pediatrics to review the previous year's performance . If she is successful on numerous criteria, she receives an amount equal to %5 of her earnings as a bonus .

To Evaluate or Not to Evaluate... Is That the Whole Question?

Physician performance evaluations are generally annual, and productivity measures are only one part of the process. Rogers requested that neither her name nor her hospital's name be used because the evaluation process is considered confidential. Having completed it a few weeks earlier, she generally welcomes her evaluation. “If this evaluation did not happen, I would be looking for another place to work,” she says. “But in this process you are assessed only on quality, not on relative value units = RVUs or billing”. Note: Relative value units are a measure of value used for physician services in the United States Medicare, government health insurance, reimbursement formula. RVUs are part of the resource-based relative value scale. Rogers likes setting personal goals with her supervisors and reviewing her progress toward them at the next annual evaluation. Most goals concern research contracts, which make up %75 of her work. On the other hand, evaluating her own performance through the hospital's RVU measure does not interest her much. Because she primarily conducts research, RVUs capture only a very small portion of her working time. Bonuses are designed to be attainable because they are paid in “stair steps,” or achievement levels, allowing even physicians who partially meet their goals to receive some payment.

Is a Bonus a Sufficient Incentive?

Nevertheless, Rogers says the bonus is not a good incentive. An amount of %5 is not enough to motivate her, she says, and its effect is further reduced because it depends on different measures such as performance, achievement of personal goals, and various quality indicators.

Evaluating the Individual Rather Than the Team

The quality indicators assess Rogers's team, not just her, because the whole team works together on each patient's treatment. Typical indicators are “central line-associated infections” and “catheter-associated urinary tract infections,” some changing annually. Rogers likes the team arrangement. Each member becomes the “champion” of a measure to encourage others to work hard toward the team goal. Alongside RVUs used throughout the hospital, her evaluation measures are determined by her department chair. She notes that doctors in different departments may have different measures because they have different chairs. Another department might emphasize people skills such as “patient satisfaction,” “communication with others,” or “getting along with colleagues.” Other organizations may emphasize administrative goals such as “completing patient chart notes.” Rogers says her hospital handles that outside the formal evaluation process. “Doctors who do not finish their notes can be suspended,” she says. “When the deadline approaches, the hospital starts warning you”.

Why Some Doctors Are Not Evaluated Regularly (or at All)

Annual performance evaluations of employed physicians are almost mandatory in large health systems, hospitals, and practices, but may be rare in small practices and some small hospitals. Dr. Rebecca Fox, a pediatrician in Charlottesville, Virginia, comments: “Many practices have no annual evaluation process, and when they do, it may be very informal and lack specific criteria,” she says. Fox learned what being the evaluator is like in her last job, as senior physician in a pediatric group with 12 physicians and 6 nurses. She says she introduced various evaluation processes for employed doctors who were not yet partners, but they did not work out well. Every process had weaknesses. She started with too many evaluation criteria, confusing doctors. She used letter grades, but some doctors became upset and even panicked when they received less than an A. She asked doctors to assess themselves, but they took weeks to complete the forms. Eventually, she dropped the requirement for evaluation meetings. Doctors received written evaluations and could submit written responses or corrections, but completing these steps took weeks. One problem was the lack of sufficient financial incentives for cooperation. A positive evaluation often resulted only in small cost-of-living adjustments.

“Once You Are a Partner, You Are No Longer Evaluated. It Is Like Getting Married. You Cannot Leave Anymore.”

She evaluates only newly employed physicians. “Once you are a partner, you are no longer evaluated,” she says. “It is like getting married. You cannot leave anymore”. Still, formal evaluations can help employed physicians. “Evaluations help them develop the habits you would want to see in a new partner.” Many practices simply reward doctors for productivity, but Fox wanted to encourage other behaviors as well. “You can have a very productive doctor who is nevertheless disliked by patients and other staff,” she says. “Or you can have a very unproductive doctor who gets along very well with others,” she adds. “We had a doctor who was very slow but got along with everyone. We kept him, but it took longer to make him a partner.” According to Fox, one valuable feature of annual evaluations is that their documentation allows a better-informed decision about whether the time has come to make an employed physician a partner. “Without evaluations, you cannot remember all the details”. And if the doctor does not become a partner and sues, the evaluation documentation can help defend the practice. - You may be interested: Why did DIGITAL HEALTH become a DISAPPOINTMENT, and how can it be fixed?

A Hospital Administrator's Perspective

Dr. James Allen, a pulmonologist and medical director at Ohio State University Wexner Medical Center East Hospital in Columbus, says that when doctors are evaluated in a large organization, they must meet management's goals. As medical director, Allen managed evaluations at the hospital. “When physicians were in a private group, they could determine the measures among themselves,” he says. “But now they must deal with management, which has its own ideas about measures. The hospital wants a measure assessed that is genuinely valuable to it. That could be patient satisfaction or readmission rates.” Creating a set of evaluation criteria requires both sides to work together. “Hospital management should work with doctors to define mutually acceptable measures for determining bonuses,” he says. “The hospital wants short stays, high patient satisfaction, low mortality, and low costs per patient. Doctors, meanwhile, want good patient outcomes and a large patient volume. Both sides must identify common ground.” All potential criteria should then be narrowed to a short list that determines bonus awards. “The bonus should be simple,” he says. “If there are more than 4 measures, it will not be clear what you are trying to encourage.” Although many doctors, like Rogers, do not consider bonuses an incentive, Allen strongly believes in them. “If you put your physicians in an environment where hard work is not rewarded, they will stop working hard,” he says. “I have seen this happen in many different practices.” However, he also acknowledges that bonuses can have unintended consequences. “For example, if you award bonuses based only on RVUs, nobody will take the night shift when there are fewer billable encounters,” he says. For this reason, he supports mixed metrics. “When you have a productivity measure and a quality measure, one metric keeps the other in check,” he says. “The doctor is productive and meets the performance target”.

Evaluation Metrics with Counterproductive Effects

Dr. Robert Centor, a semiretired internist in Birmingham, Alabama, and member of the American College of Physicians (ACP) performance measurement committee, says RVUs and other productivity measures are critical to many evaluations, but push doctors to work too quickly . Centor says: “When Medicare introduced RVUs, it encouraged doctors to spend less time with each patient,” he says. “Management's goal is to maximize revenue. To do this, it tells doctors to spend 15-20 minutes per patient. Doctors then rush from patient to patient during visits, creating stress.” “If You Speed Up Beethoven's Symphony No. 5 to Make It Shorter, You Ruin Everything.” Dr. Robert Centor, an internist in Birmingham, Alabama, says “Productivity measures from other fields do not fit health care,” he states. “They are effective in manufacturing industrial equipment, but meaningless in other activities such as health care or music. If you speed up Beethoven's Symphony No. 5 to make it shorter, you ruin everything.” “Productivity is also wasteful,” he says. When patients are rushed in and out, it adds costs to the system. You order additional tests and consultations. The organization may earn more money, but insurers must pay more. Consequently, many organizations are moving away from productivity measures toward genuine performance measures for evaluating employees. These include patient satisfaction surveys, outcome measures such as mortality and diabetes rates, and process measures such as giving aspirin to heart attack patients. “From the outside, performance measures seem like a very good idea,” Centor says. “But there are several obvious shortcomings.” Centor and others identified these problems: They may not make sense. Some measures are developed quickly, without pilot studies , or include things difficult to measure. Centor's ACP committee published a study in 2018 analyzing 86 performance measures relevant to general internal medicine and found that only %37 of these measures were scientifically sound . They may be unfair to some doctors. Doctors whose patients have little chance of improvement or do not follow medical advice will look poor on outcome measures. They encourage gaming the system. Some doctors may avoid sicker or less adherent patients to improve their outcome scores. For example, they may avoid low-income patients who bring the organization less revenue. They may focus too much on one area. A performance measure loses impact when used every year, while other measures that should be monitored may be ignored. Centor thinks evaluators should move to a new measure once old goals have been met. “Once a performance gap has been eliminated, there is no reason to focus on it again,” he says. They may focus on issues with little benefit. Process measures are easier to define than outcome measures because they can be decided immediately and usually involve uncomplicated data, but may not deliver the desired benefit. For example, many organizations track mammography or influenza vaccination percentages. Many doctors do not consider this an optimal measure. Centor adds that a conversation with a doctor about performance is more valuable than reporting a measure. For example, if the evaluated doctor has more patients with central line-associated infections, there should be a conversation about how the doctor can meet that measure. The “department chair” can approach an underperforming physician and ask, “How can we help you try to do a better job?” he says. Doctors are more cooperative with this kind of support.

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