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Conducting associate provider performance reviews is essential for ophthalmic practices
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The Way of Mastery is to break all the rules — but you have to know them perfectly before you can do this; otherwise you are not in a position to transcend them.
— Aleister Crowley
The three great essentials to achieve anything worthwhile are, first, hard work; second, stick-to-itiveness; third, common sense.
— Thomas A. Edison
John B. Pinto
It is odd, is it not? The young associate physician working just down the hall in your clinic has spent a quarter of a century in school, receiving along the way thousands of test grades and report cards reflecting his performance in hundreds of classes. And yet, if you are like the average ophthalmologist-employer, you are probably shy about confronting your associate once or twice a year with a recap of his or her strengths and weaknesses.
You may be a great surgeon, and even a pretty good teacher, but because of your reluctance you are a lousy grader. Is it any wonder your associate is not living up to your expectations? He does not know what they are.
Believe it or not, when I ask associate providers — optometrists and surgeons alike — whom they formally report to in their practice, they will commonly give me a blank stare. Then they say something like, “Now that I think of it, I’m not sure. The practice gave me an office and some exam rooms to work out of, and basically told me to holler if I had any questions. That was a year ago.”
Experience shows that only about half of the associate ophthalmologists and optometrists working in surgical practices today receive a formal review at appropriate intervals or are even clear at the time they are hired about who they will be reporting to.
We could simply reproduce here a generic performance review for your associate provider, but that would be too easy and not as helpful to you as I would like. Instead, this month’s column contains enough of the basics for you to craft and deploy your own build-it-yourself associate provider review form.
Performance reviews
Your associate providers should live formally on your practice’s organization chart. They will typically report to the managing partner (or another designated owner) for clinical issues and to the practice administrator for routine housekeeping matters such as coordinating benefits, credentialing, time off and the like.
Every associate provider, whether they are on a partner track or are a durable employee, ideally should be reviewed at least once a year; twice a year is better. As for timing, it is best to perform reviews throughout the year, keyed to the individual’s anniversary, rather than clustering everyone’s reviews in the same week. When provider reviews happen in the same week, it can foster a kind of us-them conflict, with your associates comparing notes and attempting to negotiate as a group. The review dates, whether annual or semi-annual, should be held on time. Almost nothing is more disconcerting to a staffer than to have their review delayed.
If the review is generally favorable, the reviewers should consist of one physician owner (the associate’s closest natural colleague — by age, interests or affability — works best) and the practice administrator. If the tone is a bit more “interventional,” there can be some value in having a second owner at the conference to lend weight to the discussion. It can help if one of the owners present shares subspecialty training in common with the associate. As you can imagine, a retinal surgeon will accept clinical care input better from a retinal peer than from a general ophthalmologist.
What should you measure? The short answer to this question in your unique practice is probably a pretty long one: everything you can think of that reflects a dimension of what is important to you and your practice. The list should be broken down into categories. Here is a starter list of 21 elements for you to consider. Eliminate items that are not important to you. Add performance dimensions that are important in your unique setting. This could include research or teaching, wider community involvement or committee leadership within the practice, or a scalar for the associate’s overall fit with the culture of your practice.
Comprehensive professional standards
1. Timeliness — What it takes most to be a great worker, as the saying goes, is just showing up on time. Also, does the associate complete charting, dictation and project commitments on time with a minimum of staff reminders?
2. Patient care and caring — You can lump this together or break it up into several subcategories:
a. Clinical and surgical judgment and decision making
b. Adherence to agreed care pathways
c. Treatment and surgical outcomes
d. Complications management and outbound referrals
e. Communication with patients and family members
f. General affability and the ability to bond with patients
3. Conflict resolution — Being open to difficult conversation. Being fearless about telling the truth early rather than withholding difficult news (for example, about a patient whom the associate may have made unhappy). To facilitate this, maintaining an open-door policy that easily allows access to all levels of staff, including management, owners and fellow provider-associates.
4. Absence of drama — Quells rumors rather than passing them along and amplifying them. Does not magnify small problems, imagined slights or the daily irritations of clinical practice. Does not storm down the hall when things do not go his or her way.
5. Avoids support staff fraternization — Maintains a professional but friendly distance with lay support staff. (An example: It is great to join in at an occasional, practice-sponsored TGIF mixer, but it would be inappropriate to share a night of late clubbing with the youngest staff, celebrating the head tech’s recent divorce.)
6. Practice knowledge — Maintains an intimate understanding, enhanced over time, of the various services provided by the practice, their prices, success drivers and profit dynamics.
7. Attention to detail — An extreme attention to operational detail and smooth daily operations is obliged in a complex and changing environment in which inattention is costly.
Leadership
8. Models appropriate professional behavior and helps build a foundation of leadership — Consistently demonstrates the ability to build and lead a senior staff team, and to actively mentor and coach not only departmental leaders but junior providers.
9. Planning and development — Participates in the preparation, and at least annual review, of the practice’s strategic and business operations plan. Leads or delegates the revision process for each subsequent edition.
10. Committee positions — When invited, is an effective non-voting member of the board and effectively supports the practice’s various standing committees.
11. Career commitment — Meets and exceeds the basic time requirements of the position, including occasional demands for evening and weekend meetings.
12. Recruitment — Involved from time to time in provider and senior staff recruitment activities.
Productivity
13. Overall productivity — When there is a lull in patient volumes, uses time effectively (eg, answering priority phone calls, completing dictation, returning email).
14. Volumetric performance — Meets or exceeds reasonable expectations for the number and type of patients seen. Gracefully accepts work-ins and emergency appointments.
15. Financial performance — Is on track with agreed hallmarks for collections and profit contribution.
16. Resource utilization — Uses staff, equipment and facility resources to their best purpose. Is reasonable about asking for new resources but has an understanding that not every equipment request will be honored.
17. Referral behavior — Refers preferentially, when appropriate, to in-house subspecialists rather than outside providers. Supports ancillary services (ASC, special testing, optical, low vision, audiology, etc).
18. “Coachability” — Is approachable and eager to get constructive input from colleagues and support staff. Is not defensive. Readily adopts reasonable corrective actions.
19. Sensitivity to cost containment — Actively looks for opportunities to reduce the cost of providing patient services, without eroding care quality.
20. Contributes to operational enhancements — Makes suggestions to improve practice work flow. Aids with periodic revisions to the practice operations manual.
21. Risk management — Supports the practice’s efforts to reduce malpractice and other liability. Uses good judgment to suspend or revise any clinical or business practices believed to be inappropriate.
Develop a scoring system
Every grading system needs h4 scale. Once you have decided what elements to measure, you can use the familiar ABCDF scale or count up from one (low) to five. Here is an example:
5. Outstanding performance: consistently exceeds standards.
4. Above standards: frequently exceeds standards.
3. Meets standards.
2. Below standards: infrequently meets standards. Improvement needed.
1. Unacceptable performance: significant improvement is urgently required.
Do not just score your associate from your position on high. Ask them to score themselves as well, using the same tool that you develop using this month’s column as the jumping-off point. If you need another opinion or two, before you sit down for the review, ask for input from your practice’s head tech, ASC director, optical manager or other well-placed and thoughtful individuals.
After each review session, the form you use should be signed by the reviewer(s) and countersigned by the associate provider.
A final thought: A very practical addition to any periodic review is to update the associate on your future plans for the practice and the role you see the associate playing. Of course, in the healthiest settings, the associate is being kept in the loop all along on the following topics:
- What is our service area?
- What should we become known for?
- How fast are we trying to grow?
What service lines will we enter, build on or withdraw from in the years ahead?