Help physicians adapt to performance management

What do you call a doctor who graduates at the bottom of his class?

Doctor.

There’s more than a grain of truth in the old joke that sets physicians’ practice of medicine beyond reproach. Yet, developing a successful performance management process calls for a complete reversal of this paradigm, say Theresa A. Ryan Mitlyng, MD, associate medical director, HealthSystem Minnesota in Minneapolis and Christine N. Micklitsch, MBA, FACMPE, director of physician education and services at Fallon Community Health Plan in Worcester, MA.

The co-authors of Physician Performance Management: Tool for Survival and Success (MGMA, $75) offer physician relations professionals seven tips for carrying out this tall order.

1. Understand the traditional mystique of physicians.

"Not only have physicians been trained and ingrained with the fundamental belief that the way they practice medicine is beyond reproach, but they also have a resistance — because of the pace of their practices — to commit time to learning new ways of practicing," says Ryan Mitlyng.

The health care system itself can engender norms that reinforce this mystique with such attitudes as "doctors are more important than other team members" or "professionals don’t need to share positive feelings or praise."

2. Articulate the need for change.

"We tell physicians that we can’t practice medicine today like we did 20 years ago, " says Ryan Mitlyng. "As patients, employees, employers, insurers, and government demand more accountability, physician performance becomes a critical issue."

She compares the health care system to an automobile. "Consider physicians as the engine that produces the power to drive the organization. If they perform poorly, you’ll have a sluggish response time, excessive fuel consumption, and high repair costs," she says.

3. Determine what will be measured.

"If you are just starting to develop a performance appraisal system, then the most important thing you can do at the beginning of the process is to clearly identify the specific expectations — in terms of behaviors — and competencies for each physician position," says Micklitsch.

This requires more than the typical job description, she stresses. "A job description is too general. You must get specific because without that specificity, it is impossible for physicians to know what they are expected to do," she says.

4. Set expectations early.

Such preparation will also enable you to recruit physicians who can best fit in the new model of care delivery.

"Physicians should have full understanding of the practice they are joining and how they are expected to perform in it," she says.

In the book, the authors list 19 examples of specific expectations to be communicated as part of the hiring process. Among them:

• You will care for 2,000 patients in our system within two years.

• You will return patient phone calls as soon as possible or within an acceptable time based on the patient’s expectations.

• You will have completed your chart dictation and charges by the end of each day.

• You will review refill requests and give an answer to the pharmacy within four hours of receiving them.

"If, during the interview, the physician indicates that he or she is uncomfortable with these expectations, then that is a red flag to us that the person may not be appropriate for working here," says Ryan Mitlyng.

5. Involve the participants.

Physician buy-in to the performance appraisal process can’t be emphasized enough, the authors say. "They must have a voice in reviewing and coming to consensus on the entire management system," Micklitsch warns. "If they don’t, it will be meaningless."

Physicians should review and agree upon the following:

• which performance measures will be used;

• which evaluation tools will gather those measures;

• how the information will be disseminated;

• from whom the data will be gathered;

• the weight given to each component of the evaluation.

"This consensus is especially important when data is subjective or not statistically significant because of sample size issue," Micklitsch points out. "If doctors don’t trust their data, they will not use it."

6. Appoint a trusted leader.

This is where physician relations professionals must step aside. "You may be able to help initiate and facilitate the process of developing a performance appraisal process, but only a physician leader should conduct the actual evaluation and handle subsequent action," says Ryan Mitlyng.

7. Establish and enforce consequences.

What happens when physicians don’t abide by their own parameters? That’s for each organization to decide. But decide it must. "The whole point of the physicians performance appraisal process it that physicians must bear the consequence of their own behavior — rather than having the staff or the patient suffer," Ryan Mitlyng stresses.

[Editor’s note: Physician Performance Management: Tool for Survival and Success is available from Medical Group Management Association. The cost is $38 for MGMA members, $42 for affiliates, $75 for non-members, plus shipping and handling. To purchase, call (303) 397-7888.]