How Does Your Boss Evaluate You? (It's Not Just Productivity)

Leigh Page

January 02, 2020

Susan Rogers, MD, (not her real name) gets a formal evaluation once a year at a large children's hospital on the East Coast, where she is an employed physician.

Each June, she sits down with her supervisor, the chief of the pediatrics department, and they review her performance for the past year. If she does well on a variety of metrics, she gets a bonus payment that equals about 5% of her compensation.

Performance reviews for physicians typically take place annually, and metrics on productivity and process measures are only part of the process. (Rogers has asked that her name and her hospital's name not be used, because the review process is considered confidential.)

Rogers, who is just a few years out of training, mostly appreciates having the reviews. "If I didn't have this evaluation, I would have sought it out," she says. The reviews, she concedes, have been tough at times, but they are necessary because "these are matters of life and death."

She is accustomed to being evaluated, but somewhat differently. "As a medical student, resident, and fellow, you are evaluated all the time," she says. "But in training, you are evaluated only for quality, and not for [relative value units] (RVUs) or billing."

Rogers likes the process of setting her personal goals with her supervisor and then reviewing her progress toward those goals in the next yearly review. Most of her goals have to do with research contracts, which take up 75% of her work.

On the other hand, she's less interested in reviewing her productivity, which the hospital measures in RVUs. Since she is mostly involved in research, the RVUs cover just a small portion of her work time.

Her bonus is designed to be easily reachable, because it is paid in "ladders" — or levels of achievement — so that even physicians who only partially meet their goals can still get some payment. If the entire bonus is set too high, many physicians won't try to reach it.

Still, Rogers doesn't feel incentivized by the bonus. She says the 5% figure is not enough to motivate her, and its effect is further diminished because it is spread across a variety of different metrics: productivity, meeting her personal goals, and meeting several quality indicators.

Evaluating the Team, Not the Individual

The quality indicators are used to assess Rogers' team of physicians, and not her individually, because the whole team shares treatment for each patient. Typical indicators for her team are central line-associated infections and catheter-associated urinary tract infections — and some of them change every year.

Rogers likes the team arrangement. One member of the team becomes a "champion" for each measure, making sure that the rest of the team works hard to meet the goal.

Except for the RVUs, which are used hospital-wide, the measures Rogers is assessed on were chosen by her department chief. She says measures for doctors in other departments may be very different, because they were chosen by their chiefs. Another department might look at patient satisfaction or people skills, such as communicating with others or working with the staff.

In addition, other organizations might emphasize more administrative goals, such as completing notes in the chart. Rogers says her hospital handles this outside of the formal evaluation process. "Doctors who don't complete their notes may be suspended," she says. "The hospital starts warning you when the deadline is coming up."

Why Some Physicians Don't Get Regular (or Any) Reviews

Yearly performance reviews of employed physicians are virtually de rigueur in large health systems, hospitals, and practices, but they can be rare in small practices and some small hospitals.

"Many practices don't have yearly reviews, and even if there is a review, it can be very informal, without written criteria," says Rebecca Fox, MD, a pediatrician in Charlottesville, Virginia. Why? "The review process can be very uncomfortable for the physician being reviewed, and for the reviewer," she says.

Fox learned what it was like to be the reviewer in her last job — a pediatrics group with about 12 physicians and six nurse practitioners, where she was a senior doctor. She tried to introduce several kinds of review processes for employed physicians who had not yet become partners, but they did not work out well, she says.

Each process had flaws. She started with too many review criteria, which she said confused the doctors. She used "A"-to-"F" grading, but if the doctors got anything less that an "A," some became irritated and even panicky. She asked the doctors to start with a self-evaluation, but it took them weeks to turn them in.

In the end, she stopped requiring the doctors to have a meeting. They were issued written assessments and could then submit written responses or corrections, but it took them weeks to do so. One problem was that they did not have much of a financial incentive to cooperate. A favorable review only resulted in a small cost-of-living adjustment in most cases.

Once you become partner, you don't get reviewed any more. It's like being married. You can't leave anymore. Dr Rebecca Fox, pediatrician in Charlottesville, Virginia

She reviewed only the new physicians who were still employees. "Once you become partner, you don't get reviewed anymore," she says. "It's like being married. You can't leave anymore." Still, formal reviews can help the employed physicians. "You can use the review to help them cultivate habits that you'd like 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, but they could still be very disliked by patients and staff," she says.

"Or you can have a very unproductive doctor, but they play well with others," Fox says. "We had a doctor who was very slow, but she got along well with everybody. So we kept her, but it did take her longer to make partner."

One value of yearly reviews, Fox says, is that when it's time to decide whether the employed physician should become partner, material from the yearly reviews can inform that decision. "Without the reviews, you can't remember all of these details," she says. And if the doctor is not chosen to be partner and sues, the material in the review can aid in the practice's defense, she says.

A Hospital Administrator's Perspective

When physicians are reviewed in a large organization, they have to meet the goals of the administration, says James Allen, MD, a pulmonologist who is medical director of the Ohio State University Wexner Medical Center East Hospital in Columbus. As medical director, Allen has overseen reviews in his hospital.

"When the physicians were in a private group, they could decide on measures among themselves," he says. "But now they have to deal with an administration, which has its own ideas of what should be measured. The hospital wants to review a metric that is truly a value to the hospital. It might be patient satisfaction or readmission rates."

Developing a set of review criteria involves both sides working together. "Hospital leadership has to partner with physicians to identify mutually acceptable metrics for how the bonuses should be defined," he says. "The hospital wants low length of stay, high patient satisfaction, low mortality, low per-patient expenditures. Physicians, on the other hand, want good patient outcomes and large patient volumes. Both sides have to identify common ground."

Then all of these potential criteria have to be boiled down into a small set of criteria that are used to award the bonus. "The bonus plan has to be simple," he says. "If there are more than four different metrics, then it will not be clear what you are trying to incentivize."

Although many physicians like Rogers basically ignore the use of bonuses as an incentive, Allen is a strong believer in them. "When you put physicians in an environment where they no longer are rewarded for working harder, they stop working harder," he says. "I've seen this happen in several practices."

However, he acknowledges that bonuses can lead to unintended consequences. "For example, if you only bonus RVUs, you'll never get anyone to work the night shift, when there are fewer billable encounters," he says.

Therefore, he is a proponent of mixed metrics. "When you have a productivity measure and a quality measure, one metric acts as a moderator for the other," he says. "The doctor is productive and meets a performance goal."

Review Metrics That Become Counterproductive

RVUs and other productivity measures like billings are a key feature of many reviews, but they often push doctors to work too fast, says Robert Centor, MD, a semi-retired internist in Birmingham, Alabama, who is a member of the performance measures committee of the American College of Physicians (ACP).

"When the Medicare program introduced RVUs, it unintentionally encouraged doctors to spend less time on each patient," Centor says. "Administration's job is to try to maximize income. So they tell physicians, spend 15 to 20 minutes per patient. They end up rushing through visits and that creates stress."

If you speed up Beethoven's Fifth Symphony so that it runs shorter, you've screwed the whole thing up. Dr Robert Centor, internist in Birmingham, Alabama

"Productivity metrics do not fit medicine," he says. "They are good for making widgets but they don't make sense for medical care or many other activities, like music. If you speed up Beethoven's Fifth Symphony so that it runs shorter, you've screwed the whole thing up."

"Productivity is also wasteful," he says "When you're running patients in and out, it ends up costing the system more money. You order extra tests and extra consults. The organization may make more money, but insurers have to pay more."

As a result, many organizations have been moving away from productivity measures and toward measuring actual performance in employee reviews. Performance measures include patient satisfaction surveys; outcomes measures such as mortality and diabetes rates; and process measures such as making sure to give an aspirin to heart attack patients.

"On the surface, performance measures seem like a really great idea," Centor says. "But there are some obvious flaws."

Centor and others have identified these problems:

• They may not be valid. Some measures were hastily put together without pilot studies, or they may involve metrics that are very difficult to measure. Centor's ACP committee published a study in 2018 looking at 86 performance measures relevant to general internal medicine and found that only 37% of them were scientifically valid.

• They can be unfair to some doctors. Doctors will fare poorly with outcomes measures if they have sicker patients who are less likely to show improvements or if they have patients who do not adhere to medical advice.

• They prompt gaming of the system. Some physicians may try to improve their score on outcomes measures by shunning sicker or less adherent patients. For example, they might avoid low-income patients, who also generate less income for the organization.

• They may focus too much on one area. A performance measure loses its impact when used year after year. Meanwhile, other measures that also need to be monitored may be ignored. Centor thinks reviewers should switch to a new measure once the old measure has been met. "Once there is no longer a performance gap, then there is no reason to focus on that," he says.

• They may focus on less useful issues. Process measures are easier to identify than outcomes measures, because they can be determined immediately and often involve straightforward data, but they may be less useful. For instance, many organizations track the percentage of patients getting mammograms or flu shots, which many doctors don't see as optimum measures.

Centor adds that the discussion with the doctor about performance is more valuable than just reporting the measure. For example, when the doctor under review has a higher number of central line infections, there needs to be a discussion about how the physician can meet the measure, he says.

"The department head can reach out to the low-performing doctor and ask, 'How can we help you try to do a better job?" he says. "Doctors are cooperative about this kind of outreach."

Leigh Page is a freelance writer based out of Chicago, Illinois.

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