Any healthcare employee anticipating an annual performance review is going to have several goals in mind. But being straightforward about what’s not working in the relationship with the boss surely won’t be one of them. After all, a pay raise for the next year and other perks could be on the line. Employees have every reason to put their best foot forward, tell the boss what he or she wants to hear—and keep their critiques of management to themselves. 

These dynamics, according to UCLA management professor Samuel Culbert, undermine crucial organizational goals that depend on honest exchanges among team members. He says the time is nigh for organizations of all types, including hierarchical, tradition-bound healthcare institutions, to say goodbye to the performance review once and for all.

“If you want to measure sucking up, then do performance reviews,” said Culbert, author of Beyond Bullsh*t: Straight Talk at Work (Stanford University Press, 2008). 

“If people were thinking, they wouldn’t have performance reviews. They wouldn’t have one-sided accountability. Bosses should be accountable for operatives doing good jobs. We have to talk about bosses being accountable to subordinates because once there’s two-sided accountability, then you’re likely to have some real teamwork.”

Culbert isn’t the only one who feels the performance review needs a re-evaluation. Many hospitals are pioneering new formats, such as a review that has no salary repercussions and no numeric score, according to Jeffery Payne, president-elect of the American Society for Health Care Human Resource Administration. 

Healthcare organizations are expanding their evaluation formulas, adding customer service feedback and other factors to create a “dynamic 360” review, according to Walter Flynn, a St. Paul, Minn.-based human resources consultant with a healthcare specialty.

Healthcare consultants tend to agree that performance reviews are only as effective as the participants, especially the supervisor. If the person administering the review is too chummy with employees or avoids difficult conversations, the argument goes, then even a well-structured performance review is unlikely to serve the purpose of improving an employee’s contributions to a company. 

“People are afraid to provide negative feedback, which is why they try to avoid doing performance appraisals in many cases,” said Ken Kruger, president of the Health Care Human Resources Consulting Consortium in White Plains, New York. “They don’t know how to put it in a way that helps the individual understand and grow.”

Previews are better than reviews

Such tinkering with performance review practices is not adequate, in Culbert’s view. He wants performance reviews discarded everywhere, even in hospitals, nursing homes, and physician group offices. He acknowledges that Joint Commission accreditation requirements include periodic performance reviews, but he says such oversight guidelines are sufficiently broad to allow for radical changes to current practice.

Culbert advises organizations to replace performance reviews with what he calls previews. Pay levels aren’t at stake in a preview, he said, because those are determined by market forces rather than individual performance anyway. 

Supervisor and subordinate look forward, not backward, in a preview to explore how they might better work together for optimal outcomes. Importantly, in a preview, a manager shares accountability for his or her employee’s performance. And previews happen not once a year but whenever either party feels the working relationship could benefit from a tune-up.

“How many bosses go up to employees and ask the most basic, essential question: What do you need from me so that you can do a better job?” Culbert asked rhetorically. “That’s a preview.”

Culbert noted that technical competencies of individuals still require evaluation. That can and should be done in a separate forum, such as an objective exam. Yet even the most technically oriented worker will likely do a better job, Culbert said, if he or she is liberated to admit weaknesses and seek help without having to worry about potential consequences in a looming performance review. 

Can you coach?

Those who specialize in healthcare human resources have doubts about jettisoning performance reviews altogether. Some say much would be lost if accountability for performance were to come to rest with more than one person.

“The healthcare business is based on trust,” said Jim Campbell, executive director of HealthCare Compliance & Consulting Resources in Nashville, Tenn. “Part of that is accountability on an individual basis. If that somehow becomes diluted so there is no longer individual accountability but rather there is group accountability, then typically what I’ve seen is that everyone’s job becomes no one’s job.”

Others praise Culbert’s idea in theory, but say it’d be impractical in the healthcare industry. Flynn notes that in some hospitals, as many as 60 nurses report to one supervisor. To expect such a supervisor to conduct meaningful previews on an ongoing basis with every subordinate would be unreasonable, Flynn said. 

Instead he believes managers need training in how to coach subordinates, which he says many don’t receive when they’re promoted. They should then apply soft skills to make performance reviews into more candid exchanges. But he notes that bringing such training to fruition, especially in smaller institutions, can be an uphill challenge.

“A lot of my clients are clinics or physician groups with 100 employees and maybe a half a dozen managers,” Flynn said. “They’re reluctant to spend the time, let alone the money, to train people in supervisory skills. That’s until there is a negative outcome and they fire somebody summarily with no documentation and argue that it’s performance-based. Then they get a lawsuit or a discrimination charge and wish they had done supervisory training. I deal with that constantly.” 

Flynn noted that Culbert’s previews would require even more supervisor training than traditional reviews because previews would demand more nuance and skill. Lining up such training is unlikely to happen in many healthcare settings, Flynn said. So performance reviews may be around, in one form or another, for some time to come, and some argue that’s good news for employees. 

“Employees want to know how they’re doing,” Kruger said. “You can fault the methodologies when performance reviews aren’t put together right, but there are ways to do it appropriately.” 


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