White Paper Guide: Healthcare Leadership

A changing healthcare environment has resulted in an increased focus on performance, both at the organizational and personal levels. Healthcare leaders carry an added burden—an increased need to focus on both operational performance (clinical and functional) and non-clinical performance (behavior, leadership, and interpersonal skills). Many healthcare organizations are effective at measuring the clinical or functional components of job performance. Yet few are as equally competent when it comes to assessing the non-clinical or behavioral performance components. Without considering both performance measures, healthcare organizations may not have an accurate view of how their leaders truly perform.

The Failing Performer

One significant benefit resulting from increased legislation, monitoring, and public scrutiny (as well as auditing entities) is that the proficiency in measuring clinical and functional aspects of performance has increased. These include measuring job-specific skills considered “must-haves” in a healthcare manager’s repertoire. Clinical knowledge and ability, education, training, licensures, and experience are prime examples. These skills are critical for professionals who work directly with patients, as well as those who are primarily administrative. Unfortunately, our ability to look at the behavioral aspects of performance has not kept pace with our capacity to understand and measure the technical, and operational components.

Performance measures in healthcare based solely on clinical skills misses a critical factor—behavior, or the “soft side” of performance. For patient-facing managers, this soft dimension is referred to as the non-clinical, operational, or interpersonal side of performance. For managers who are not primarily patient-facing, this takes the form of interpersonal or non-functional performance (behavior that is not a job- skill-specific). Regardless of terminology, it is clear that performance goes beyond points listed on a résumé. Many organizations, however, fail to adequately consider both sides— clinical/functional and non-clinical/non-functional—when looking at manager performance.

Managers lacking in the non-clinical/non-functional side of leadership typically experience significant issues that eventually decrease overall performance. On an individual level, this could take the form of ineffective leadership, poor relationships, inability to gain respect, and generally poor results. On an organizational level, this often results in high turnover, disengaged employees, and a lack of teamwork, which will eventually impact patient care.

Functional Versus Behavioral Performance

DecisionWise, a talent management and performance assessment firm, recently completed a three-year study involving nearly 200 employees scattered across several facilities. One purpose of this study was to identify the correlation between functional, job-specific performance and interpersonal or behavioral performance.

Employees were evaluated each year for three years using a standard performance appraisal provided by the employee’s supervisor. Each employee was then evaluated through multi-rater (a.k.a., 360-degree) feedback, consisting of input from supervisors, peers, direct reports (when applicable), and others with whom the employee worked. One key difference between the two types of evaluations, aside from the number of raters, was that the multi-rater feedback also contained several “soft” factors. Included in these soft factors were dimensions such as communication, team building, leadership, interpersonal skills, and integrity. Similar to the standard performance evaluation, these factors also included functional skills, such as getting results, safety and regulatory compliance, job-specific skills, and service levels.

Surprisingly, there was no correlation between a person’s annual performance evaluation and his/her multi-rater assessment. This put the findings in question, as one would anticipate that the correlation would be strong. However, the reason for the lack of correlation soon became clear. Employees receiving the highest annual performance evaluation scores also scored the highest in the areas related to functional skills. In other words, supervisors typically saw performance in terms of day-to-day, job-specific operational performance.

On the other hand, peers, subordinates, and others rewarded employees who focused on interpersonal skills, leadership, teamwork, relationships, and communication. Co-workers who interacted daily with these employees were in a better position to recognize such skills. Typically, the employees’ managers were not as involved daily and were not as quick to see the non-functional side of an employee’s performance.

Performance – The What and the How

When measuring the overall performance of healthcare managers, what are the critical components? First, it’s important to note that true overall performance combines both clinical/operational performance (the what— held in high regard by the employees’ managers, in this case) and interpersonal performance (the how—as indicated by coworkers). We find that leaders can, in the short term, get the right clinical or functional results while leaving a wake of destruction in their paths. True performers, however, excel in both operational and interpersonal performance.

Another common theme exists in healthcare organizations—that of promoting the best “doers” and expecting them to be good managers. We identify employees with excellent clinical (or functional) skills and then say, “They are the best (nurse, physician, accountant…) we’ve got!” When it comes time to fill open positions, we promote the employee with the strongest clinical or functional skills.

As a manager, however, the need for interpersonal performance quickly becomes even more critical. Tragically, we soon realize we’ve promoted the best doer into a management role, creating both a poor manager and losing our best clinician!

Performance measures based solely from a clinical skills perspective misses a critical component—the behavioral, or the “soft side” of performance.

UMC Health System in Lubbock, Texas has been quick to pick up on this concept. UMC is the primary teaching hospital for the Texas Tech University Health Sciences Center. In evaluating and improving overall performance, UMC recognized that successful managers were those who possessed both functional skills and interpersonal skills.

Adrienne Cozart, Vice President of Human Resources for UMC, states, “We noticed that there were metrics outside of clinical ability that help us understand our performance and build a successful team. In the case of our employees with direct patient contact, it takes abilities beyond clinical skills to lead successfully. A nurse with excellent clinical skills can only succeed to a point if he or she does not have non-clinical and leadership skills.”

Cozart considers the same to hold true for administrative positions. “Those not directly caring for patients must also perform beyond the job-specific, technical requirements of their jobs. We find that, in healthcare in particular, how we get things done is just as important as what gets done.”

UMC has taken performance measurement and accountability seriously. In addition to focusing on the functional or clinical aspects of performance, UMC holds its leaders responsible for the non-operational aspects as well. Evaluating whole performance by using additional measurements, such as employee engagement, patient satisfaction, and 360-degree feedback assessments have provided UMC with a more complete picture. “Using a combination of clinical and non-clinical measurements has helped us gain an understanding of how our leaders are truly performing. We have a more complete picture of those who are succeeding, as well as where to focus our development and coaching efforts,” indicates Cozart.

Measuring Both Sides

Clinical or functional ability is at the base of healthcare performance. This is the “price of admission” – the basic requirement for entry into a healthcare capacity. However, these skills do not always ensure success for a manager. They’re far from it.

Unfortunately, in reviewing performance, many healthcare organizations ignore the “softer side” by viewing the interpersonal and behavioral skills of their managers as “nice-to-haves.” Yet lack of interpersonal performance is something that generally cannot be compensated for by even the strongest of clinical skills.

An organization must do more than simply preach the criticality of interpersonal and non-clinical performance. Organizations that recognize this fact do three basic things that set them apart:

  • Hire and promote both sides of performance. When considering staffing decisions, they look beyond clinical and functional abilities. Functional skills are must-haves. However, they are only part of the picture. Evaluating such factors as how this person will lead, communicate, inspire, and work with others is a critical piece of anticipating Investing the extra time to understand these potential “soft skills” will pay dividends.
  • Recognize and reward managers for interpersonal Many organizations treat interpersonal performance as an afterthought. However, recognizing managers for the non-functional side of performance helps the organization understand that both dimensions of performance are not only important but also expected.
  • Take a pulse. Assessments such as 360-degree feedback and employee engagement surveys go beyond just the functional or clinical aspects of performance to get at the interpersonal Yet, a culture of feedback based on non-functional measures is foreign to many organizations. Feedback from colleagues beyond a supervisor generally sheds some light on how performance is perceived by others.

Raising the Performance Bar

Healthcare leaders are under increased pressure to raise the performance bar. There are heightened requirements to deliver superior customer and patient care in an often difficult environment. Regardless of the reasons why, it is important to look at both elements of performance—the clinical or functional and the interpersonal. Each element plays a critical role in the overall effectiveness of a manager or an organization.

CHG Healthcare Uses Feedback to Predict Performance

DecisionWise recently published an article in T+D Magazine that highlighted a three-year study with CHG Healthcare. CHG was looking for a method to identify not just functional and clinical performance of its managers, but also interpersonal performance. They used a combination of four instruments: 1) A traditional performance appraisal (conducted by the manager), 2) A service report card (analyzed the level of service provided by the manager and his/her team), 3) Employee engagement scores from each managers’ units or departments, and 4) A customized 360-degree feedback instrument.

“We noticed something interesting when we looked at feedback and performance,” stated Kevin Ricklefs, CHG’s vice president, administration. “We found that 360-degree feedback not only provided an understanding of a manager’s past behavior, it also acted as a predictor of future success. When we placed these individual results side-by-side with the employee survey results of that same manager, we saw they were directly related. Then when we looked at that manager’s performance, the relationship was clear.”

CHG Healthcare understood the importance of both dimensions of performance. CHG ensured that, in addition to continual review of the financials, it would also keep a regular watch on the “softer side” of organizational performance. “We see 360-degree feedback and employee engagement as part of our total performance metrics. Low 360 scores are a warning that employee engagement is likely to decrease unless something changes. Poor engagement scores are a signal that team operational performance will suffer down the road,” said Ricklefs.