Managing Physician Performance in Hospital Medicine

Here are a few points to consider as you integrate your compensation system into the rest of the steps in the pyramid:

1. A straight salary with or without a “guaranteed” bonus is unlikely to reward or motivate any new behaviors.
2. For a performance-based compensation plan to have sufficient impact, at least 20%–30% of compensation must be tied to performance.
3. Consider having both group and individual measures as part of your plan to engender a sense of teamwork and collective effort in performing well.
4. Limit the number of variables in the plan to 3–5; otherwise, measures are too diluted to carry meaningful weight.
5. Perform a local market comparison for benchmarking your goal median compensation; often administrative staff are more willing to share this information with other administrative staff if the understanding is that all market results will be shared.
6. The process of constructing or evolving your plan, being inclusive of members of your group as well as any group sponsors, ends up being far more valuable than the final plan itself.

Providing Regular Feedback

Have you ever had a complaint that sounded like “I get way too much feedback around here?” Probably not. More likely is the case that your hospitalists wonder how they stand in terms of being compared to others and to themselves over time. The creed “no news must be good news” is hardly supportive of promoting top performance. Feedback itself can be highly influential and reflects the expectations explained by the group leader. Expectations not measured or fed back to the individual hospitalists will be expectations soon forgotten or ignored, because they may be felt not to matter.

Effective feedback is both formal and informal. The annual performance review is a common example of the former, but it is in no way meant to be the only feedback a hospitalist should receive, nor is it the most powerful. The annual review should be well structured, can outline longer term goals and ideas for self-improvement, and may serve in some key administrative functions like compensation and promotion. Informal, regular feedback, however, may serve you much better in driving performance, because it is timelier, more relevant to daily work, and more specific to the individual. Individuals also respond much more constructively to positive feedback, and some experts believe the ratio of positive to negative feedback should be on the order of 9 to 1. Be sure that feedback is done in a coaching manner and focuses on the behavior (You may try sitting down when you talk with patients as a way of making them feel more at ease) rather than on the person themselves (You’re really not a good communicator).

Managing Marginal Performance

Marginal performance can be defined as a physician whose observed behaviors or measured outcomes are at significant variance from what is expected. This pattern takes place over time and happens in spite of having in place all the other elements of a performance management system. Consider the “clock puncher” who rarely helps out the rest of the team on busy days and never shows up to group meetings or committees. Or the “tortoise” that has wonderful staff relations but chronically arrives at work late and repeatedly forgets to submit inpatient charges. Then there’s the “hothead” who is clinically adept and has high patient satisfaction but loses his or her temper with nursing and is pervasively confrontational with consultants. The steps to be taken in these and other cases like them include ensuring adequate documentation, reaching an agreement with the individual in recognizing that there is a problem, generating options for causality, negotiating a contract for improvement, and then letting future behavior determine the consequences.