Weeding Out the Weak

Molly Rowe, for HealthLeaders Magazine , November 1, 2007
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It's a familiar story: Hospital X spends months planning to implement, say, a medication reconciliation process. The hospital develops a new form, conducts pilot testing, trains staff members until they're checking "reconciled" boxes in their sleep, and finally launches the process hospitalwide. A year and 20 process redesigns later, senior leaders are still trying to figure out why the process won't work.

New hospital initiatives have a 60 percent chance of failure, says healthcare management expert Quint Studer, founder and chief executive officer of the Studer Group. That's a pretty high figure considering the number of initiatives (like medication reconciliation) that are required each year to meet state and federal requirements or to participate in different patient safety organizations. Many of these floundering projects are critical to a hospital's success. So what goes wrong?

The success or failure of an initiative depends largely on the people, Studer says-specifically, a hospital's ability to deal with its underachievers. "In healthcare, not only can we not deal with low performers, we can't talk about them." Job descriptions and annual reviews in healthcare tend to focus on competency, but most reviews don't capture excellence-a trait critical to a hospital meeting its quality, patient safety and financial goals. Take, for example, the physician who attracts patients to the facility but is consistently rude to staff or the senior manager who's been around for years but never meets his goals. Such employees can hold a hospital back.

Low performers
Palmetto Health Baptist Easley in Easley, SC, began taking a closer look at these types of employees three years ago. Prior to that, Baptist Easley, like many hospitals, conducted annual competency-based reviews. The reviews helped identify 63-staffed-bed Baptist Easley's best employees, but sometimes enabled the hospital to ignore the worst, says Chief Operating Officer Roddey Gettys. "Those low performers are the ones who suck the life out of the rest of the employees. They are the habitual complainers, whiners, moaners, groaners. Their work performance is affected by their attitude, and it tends to rub off," Gettys says.

Working with the Studer Group, senior managers categorized every Baptist Easley employee as a low, middle or high performer based on attitude, problem-solving, and eagerness to learn-as well as competency. Managers began spending more time on the high performers, rewarding them with gift cards and thank-you notes and continuously "re-recruiting," Gettys says. Low performers were given a 60-day no-nonsense warning: Change your performance or change your job.

The latter part of this warning was risky. Baptist Easley is within 15 minutes of two other large systems with which it competes for patients and employees.

"We were concerned if we got rid of them, we might not be able to replace them," Gettys says. To Gettys' surprise, morale went up, not down. High performers stepped in to cover shifts that couldn't immediately be covered by an outside agency, and employee satisfaction scores soared. "What we heard when we began walking low performers out of the hospital was high performers applauding, sending notes to say thank you," Gettys says.

Recruit excellence
Word of Baptist Easley's new work environment spread to the community. In June and July, 1,101 people applied for jobs at the hospital, which only employs 650 full-time people. Gettys estimates that 15 percent to 20 percent of those applications are for clinical positions.

Under the new performance review system, job applicants are reviewed differently to ensure that the people coming in are competent and high quality. "Every applicant is required to read and sign a commitment form, saying 'I understand I'm expected to be an exceptional employee. I understand that I will be expected to perform at a very high level. I understand that my job depends on it.' We don't let applicants fill out an application until they sign that form," Gettys says.

Tough conversations
At Sacred Heart Hospital, Chief Operating Officer Faye Deich expects to lose employees-that's how she knows the review process is working. Located in Eau Claire, WI, the 200-staffed-bed hospital uses Studer's low-middle-high process to evaluate its 1,300 employees twice a year. All levels are ranked, from housekeeper to Deich herself. Studer estimates that about 8 percent of hospital employees will fall into the low performer category. One-third will improve, one-third will self-select out of the organization, and one-third will need to be let go.

"There were people who I thought would never change who moved up and improved dramatically. I was really surprised, to be honest. And then we've had some people who could not change, and we've parted company," Deich says.

Not every leader is eager to address poor performance, especially when employees are basically competent. Jennifer Forgie, managing partner for OnPoint Consulting, a New York City leadership consulting firm, says managers don't always see managing people as a critical part of their role. This is especially true in healthcare, where managers are often promoted from clinical or technical areas and are faced with human resource or finance issues.

To improve their management skills, Sacred Heart managers are trained to have "tough conversations" using role playing and regular leadership development, Deich says. Leaders are taught to understand that these ongoing conversations are part of the job. "Leadership isn't a popularity contest, so if that's why you went into this, you may be misaligned because this is one of the things you have to do," Deich says.

Molly Rowe is leadership editor with HealthLeaders magazine. She can be reached at mrowe@healthleadersmedia.com.

Who's on your team?
Hospital management consultant Quint Studer puts employees into three categories: low, middle, or high performers.

Here's how they look:

High performers: High performers are solution-oriented people. They don't just complain about a problem on a unit or in the work force; they bring solutions. The high performer wants opportunity, responsibility and training. She can almost watch something be done and do it herself. And she has enough confidence to confront a leader with issues.

Middle performers: Middle performers understand and identify problems but don't always have the experience, training or confidence to come up with solutions. They need a little more hands-on training. Middle performers are less likely to confront a peer because "they know they're not a finished product themselves," Studer says.

Low performers: Low performers point out what's wrong and neither offer solutions nor take ownership of solving the problem. They blame someone or something else so that they don't have to do anything. Rather than taking longer to learn, low performers just refuse to learn, and they are territorial, often using the phrase, "That's not my job."

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