By Ron Rosenberg, MPH, PA & Curt Hill, CEO
With Excerpts from Coaching and Mentoring for Dummies , Marty Braunstein, IDG Books Worldwide, Chapter 6, “Setting Performance Plans the Smart Way”.
As the practice owner (or manager), one of the most powerful points of leverage you have for having your practice be effective and successful is your staff. While you are ultimately responsible for virtually every aspect of the practice’s operations, and you could view your job as single-handedly accomplishing all of it, in the day to day reality of running your business, you have staff to accomplish most of those tasks. They act as your proxy and operate at your direction.
A common shortcoming of business owners and managers is an insufficient level of communicating clear direction and expectation to the people that work for them. If your staff isn’t crystal clear about your expectations, there is a very good chance the job they do won’t fulfill your expectations and won’t get done to your standards. When that happens, you can only look to yourself as the source of the shortcoming.
The question then, is how do you have your staff operate at a level of performance that is consistent with what you would expect from yourself? Given that your staff interacts with your patients far more than you do, this becomes a vitally important question for the success of your practice. Does your staff know what you expect from them? Are they clear about the standards of performance you are holding them to? Do they have achievable goals they are working toward while they are handling the day to day business of running your practice.
Creating performance plans – clear, specific and measurable – is one method for giving direction to your staff and insuring that they are working on what is consistent with your intentions for the practice. Further, it gives you and them something against which to measure to assess their effectiveness in getting the job at hand done. This provides you, the practice owner or manager, invaluable feedback on how your staff is doing and where they need development. Taking the time to put performance plans in place is a worthy investment for the future success of your practice.
Marty Braunstein, the author of Coaching and Mentoring for Dummies , speaks of performance plans as one of the “five pillars for building commitment” – the commitment you need to elicit from your staff so that they are accomplishing the tasks at hand consistent with the performance standards you set and to which each staff-member commits.
Braunstein writes of the “doer approach” to management – supervising staff that are working hard and are always busy, but not accomplishing what is needed to have your practice run at peak efficiency and effectiveness. This is what management often devolves to without performance plans in place.
Key ingredients of Performance Plans:
There are four key ingredients to successful performance plans:
- Goal (or Objective) – A performance effort you want to accomplish or a target to reach;
- Standards – Standards go along with goals, but speaks to a behavior expectation, or standards of work exhibited in pursuing the goal;
- Action Plans – The design, the roadmap, for reaching the goal;
- Measurement – Measurable milestones and endpoints to allow everyone involved to know when the goal is reached.
The first two, Specific Goals (what to accomplish) and Standards (how we will behave as we pursue the goals) are the core of performance, and the second two are the tools for knowing how to accomplish the goals and how to know when we’ve reached the goal.
Braunstein next outlines tools for creating effective plans. He speaks of the SMART way:
S = Specific and Clear – A one-sentence description of the goal or standard;
M = Measurable: When a statement of the goal or standard is read, the reader can tell that the results sought can be measured, and it will be clear when the goal or standard has been met;
A = Action-oriented: Action verbs lead and drive the goal or standard statement. Here are some examples with the right pizzazz for goals: develop, achieve, implement, create, produce, and maintain. Remember though, the action should have a measurable outcome;
R = Results-focused: This answers the so-what factor – what are you hoping to gain, what is the reason you want to do this, what are you looking to accomplish? What difference will it make for the practice? After you and your staff comprehend the results focus, the “aha” kicks in (Aha! Now I get it). And writing goals and standards becomes easy to do, and it will become easier to get your staff’s commitment aligned with yours.
One of the keys for success in performance plans is to make them results oriented, rather than action oriented. An example would be describing a goal as “Remind each patient about their co-payment amount at appointment scheduling, reminder call, and when arriving at the office”. This wording is more appropriate for an action plan. The goal oriented wording could be “Collect co-payments at time-of-service for 90% of patients with co-payments collectable at time-of-service” (excluding Medicare patients with supplemental insurance).
T = Time Frame: The “By When”! If you are implementing a new standard such as the 90% co-payment collection, it may not be achieved instantly. If the practice is currently collecting only 50% of the co-payments, the time frame may be worded “60% at the end of month one, 70% by the end of month two, 80% by the end of month three, and the goal of 90% by the end of month four”.
Measuring Achievement of Goals and Standards:
Here are some of the ways to monitor the achievement of the goals in your plan:
Quantifiable : Quantifiable means measurement by numbers: patients seen, eyeglasses sold, frame upgrades sold, lens upgrades sold, appointment slots filled. These numbers are usually key indicators that practices count and track, so goals in these areas are often easy to measure. And thanks to computers, the sta tistical reports showing the results are often at your fingertips.
Feedback and survey : Constructive feed back on performance is another measure of how someone is performing. This feedback, to measure a performance goal or standard, can come from you and from other sources, such as internal (other staff, physicians) and external (patients) customers. A survey is a more formal means for gather ing customer feedback and a great way to measure customer satisfaction with the service you are working to deliver
Audit, Test, Inspection: An audit is the use of external data to measure performance. An example would be the comparison of the operating room logs compared to surgery charge data to measure the effectiveness of surgical charge capture. A test is an independent measure of the effectiveness of work – for example, random re-refractions of patients refracted by a technician to measure accuracy. An inspection could be a review of a random sample of patient histories taken by a technician. An extreme, but effective test, used by Medicare to uncover or confirm suspected fraud, is to send a “test” patient to an office, with a programmed history. A practice could also use a test patient to assess the entire patient flow system in a practice.
Documentation: Reports, plans, correspondence, and other documents can be records that a planned result has occurred. Patient forms such as HIPAA privacy notices, Medicare Advance Beneficiary Notices, Medical Record Releases, etc., are all examples of documentation. Another example would be a compliance plan, the completion of which was part of a performance plan for a staff-member. The plan itself would be the documentation of completion.
Timelines: Again, the “by when” part of a component of a plan is a key measure of success. Any component of a plan without a by-when is not likely to be measurable for completeness. Some tasks, specially large ones, will require interim milestones, as well as endpoints.
Work Products and Samples: This is simply a spot review of work. For example, the manager takes a random sample of EOBs and reviews the accounts to determine the accuracy and completeness of payment posting.
Observation: This is the act of moving through the practice and observing various departments. Watch how the front-desk functions. Follow patient flow. Observe the billers. These activities can be invaluable in determining how various staff-members are performing in achieving their plan.
You can use some or all of these means to measure goals and standards. It may be useful to define, for yourself, how you will monitor each goal and standard of each performance plan as the plan is agreed-to by you and the staff-member.
Here are some sample performance plan components:
Sample # 1
Goal: Create and implement process improvements that reduce the current cycle time for month-end billing system closing activities from four days after month-end to two (50%) by July 1, 2003.
1. By March 15, 2003, document current processes for handling month-end-closing activities and the average time for each process.
2. By April 30, 2003, gather input from other staff in the department and draft a plan for a streamlined process.
3. After reviewing the streamlined plan with management, perform a test run of the process improvements for May’s month-end closing.
4. Evaluate the test results and make necessary modifications to handle June’s month-end closing.
Primarily, the cycle time for month-end close, starting June, 2003
Secondarily, the documented process improvement plan
Goal: By July 1, 2003, develop a Refractive Surgery Marketing Kit that provides the LASIK coordinator and the physicians with tools that they find useful in increasing their effectiveness in scheduling LASIK procedures.
1. By Feb. 15, 2003, survey the physicians and LASIK Coordinator to assess their needs for marketing literature and other items that will help their sales efforts.
2. By March 1, 2003, gather samples of marketing materials from other practices and LASIK marketing firms.
3. Working with marketing communication vendors, by April 1, 2003, draft literature and create product samples and other necessary items for a prototype marketing kit.
3. By May 1, 2003, conduct focus groups of practice staff, physicians, and select patients to test the value and usefulness of the marketing kit.
4. By June 1, 2003, complete necessary modifications of marketing kit based on feedback gathered from the focus groups.
5. Conduct training sessions with the physicians and LASIK coordinator to familiarize them with how to use the marketing kit in their presentations to patients , completed by July 1, 2003.
The goal of the performance plan is to encompass the staff-member’s total performance – that is, every aspect of their job
SMART performance plans are meant to encompass the person’s total perfor mance. How employees spend their time – the tasks and activities they are doing – is tied to the results or outcomes they need to produce. You don’t want your employees spending time in areas that don’t produce the results needed. If they’re spending time in something that you think is important, make sure a goal or standard is set to capture that area of performance, not just the fact that they are “busy” for eight hours a day.
Therefore, goals aren’t something extra in an employee’s performance. They are the focus of the employee’s performance. Everything each individual works on and all the key job-related behaviors needed are aimed at producing meaningful results. They are part of the total performance plan.
When you manage by plan in this way, you help your employees make the shift from an activity focus to a results focus. They can see their jobs on the br oad-perspective level; that is, how what they are seeking to accomplish helps the practice be successful. (It’s as though you are saying, “Sorry, you are no longer being paid to shuffle paper and mindlessly fill out forms. Now you have to accomplish goals that serve patients well and run processes efficiently.”
You join in this shift when you manage as a coach with performance plans because how your employees spend their time becomes much less important than the results they are producing; how they do their jobs becomes less important than the outcomes they are achieving . For example, with a receptionist, when you make the shift, your focus swings from things like whether the employee is spending time with personal phone calls to whether the desired number of patient appointments are being made, empty appointment slots are filled, and co-payments are being collected.
Constructing Effective Plans:
Effective performance plans can include:
- Output targets;
- Quality indicators;
- Service expectations for patient satisfaction;
- Major projects;
- Important solutions or changes needed;
- Key duties and skills to be used to produce results;
- Areas for performance improvements;
- Key job-related behaviors for reinforcement and for maintaining results;
- Attendance targets;
- Professional development.
A plan should have five to eight goals and/or standards, no more than ten. Plans with goals and standards in the double digits become unmanageable for both the administrator and the staff-member, or, you have a task list and not a results-focused plan.
A tip in getting used to designing effective plans is to begin with your own plan.
Working with Staff to Mutually Set Performance Plans
The key to aligning commitment with employees is to set plans with your employees, rather than for them. It’s a mutual process, something you do together. The employee should walk away with a plan filled with their goals, not yours. The mutual plan development process is required for the employee to own their goals.
Your role as a manager in this two-way process is to provide the employees with direction. Tell them where the practice and their department in the practice are going, what the high-level targets or objectives are, and what key issues to tackle. The role of the employees is to set challenging yet attainable goals and standards that align with this direction and to outline the key steps or roadmaps (the action plans) on how to achieve the goals or standards.
You certainly contribute input and ideas to this discussion, not as to the way things are to be done but as part of a two-way, give-and-take dialogue to help shape the performance plans, which the employees will own and for which they will be accountable. Letting employees step up and take responsibility are a key to coaching success and building commitment.
Because many employees initially may not be familiar with how to set results- based performance plans, here is a good process to follow to mutually set plans:
1. Prepare your employees for the meeting to set their performance plans.
Provide direction on the priorities and targets for the coming period. To help your staff understand this direction, give them a copy of your own performance plans. Doing this also helps them understand the key ingredients that go into a performance plan. Ask them to come ready with a list of ideas for their own goals and stan dards that align with this direct ion. Here are a few questions that stimulate thinking:
a. What should you accomplish to help the group achieve what it needs to accomplish?
b. What changes or improvements need to be made to help us work more efficiently?
c. What key behaviors or responsibilities need to be reinforced or maintained to achieve high levels of performance?
d. In what areas of performance do you want to seek development?
2. Facilitate the planning meeting.
At the one-on-one planning meeting, incorporating the employee’s ideas, draft each performance plan one at a time. Maintain a two-way conversa tion and have the employee do the writing as together you shape the plans. Go in this order for each plan:
• Write the Goal/Standard statement following the SMART guidelines;
• Outline the action plan;
• Define the measurement of progress (Benchmarks, milestones, endpoints, targets)
Mutually agree on the goals and standards, and then have the employee take the lead in drafting the action plans portions. In many cases, the employee is THE expert on their job. You provide the coaching on the goals, they design the action.
Remember to keep the practice’s overall goals and priorities in front of you, and design each staff-member’s plan in a way that forwards those overall goals.
3. Finalize the Plans.
Review the plan with the employee and mutually “sign-off” on the completed plan.
As your employees become more familiar with the plan-development process, subsequent years will be much easier to complete, with the employee taking on much more of the load.
Review the plans, monitor progress, and update the plans (with the staff-member) as required. Some plans will need to be augmented if there are short-term projects that get completed before the next years’ plans are due.
While the prospect of creating a performance plan for each employee may seem daunting, the payoff can be substantial in the practice’s performance.
The initial set of plans may be kept simple in order to get them completed. Another tactic is to limit the staff members with plans the first year.
If your practice is larger, you may begin the process with your supervisors. The process could be:
- First, create your own performance plan as the prototype, both for defining the practice’s priorities and to design the plan format;
- Next, work with each supervisor to create their personal and departmental plans;
- Have each supervisor work with their staff to design the individual plans for their department staffers.
Remember, you currently have, at a minimum, performance expectations for each staff member in the practice, in your mind – a very dangerous place to store those expectations Formalizing those plans, creating written documents, and establishing aligned commitment from each staff member, will greatly increase the likelihood that your staff will be able to work to your standards, and the practice will operate to your expectations.
PMRG’s work with practices in consulting, computer systems, and outsourced billing, is oriented around these principles. PMRG President, Ron Rosenberg, PA, MPH has written and lectured extensively on these topics for Medical Publications and Professional Associations over the last 10 years. The list on the left is a sampling of those articles authored by Ron, including many originally written for the American Academy of Ophthalmology (www.aao.org).