By John Carruthers, staff writer, August 01, 2011
Dealing with employee difficulties can put a major strain on dermatologists and their practices. But according to human resources consultants, employment lawyers, and dermatologists who lecture on practice management at the American Academy of Dermatology’s Annual Meeting, it is possible to develop a process for assessing whether an employee can perform at the required level. By installing the architecture for performance expectation, monitoring, and improvement, these experts say dermatologists can ensure that their offices run smoothly.
Defining a baseline
Even before performance issues arise, it’s important to be able to communicate exactly what expectations you need the employee to meet, what a potential failure means to the practice, and how an underperforming employee can best get back on track, according to management consultant Janine Sergay of The Sergay Group. This process begins with a well-written job description that clearly elucidates expected performance. The baseline for expected behavior, she said, must be firmly set before an employee can be accused with violating that expectation.
“Too often, what happens, especially in smaller practices, is that there’s a job description somewhere, so you just expect an employee to know how to perform up to it. But in reality, it may not have been updated recently, and is unclear on what is specifically expected of the employee,” Sergay said. “When you go and review and find that someone’s performance is not up to par, how do you know? You haven’t set the standard. How can you possibly review anyone if you don’t have anything to review it against?”[pagebreak]
According to Milwaukee dermatologist Neal Bhatia, MD, who gives regular practice management presentations at the Academy’s annual and summer meetings, a well-constructed job description can be the most effective way to reconcile the demands of the position and the sometimes-exaggerated credentials of a new hire or potential candidate.
“Some candidates say they have a lot of experience coming in but don’t always really live up to what you expect,” Dr. Bhatia said. “Worse, some say they can do something and they’re unable to get it done. It highlights the importance of a really good detailed job description, where you’re able to set out from the very beginning exactly what’s going to be demanded of them in the position.”
Preparing to act
The most difficult aspect of performance issues in the workplace, according to Dianne Shaddock Austin, founder of consulting group Easy Small Business HR, is identifying and approaching the problem quickly, and with the proper mindset. Employers in smaller offices, Austin said, often fear being seen as the bad guy, which can lead to a hands-off approach that allows a potential issue to grow into a major problem. Waiting, she said, only makes matters worse.
“You can prevent problems by having a system in place before an issue occurs, as well as being ready to handle issues as they occur. What I have found over time is that employers are reluctant to address problems as soon as they occur,” Austin said. “Either they’re coming from the perspective of being too busy or there’s a fear or sense of intimidation to directly speak with the employee when they first see problems occurring. It’s important to address issues when they occur before it gets to the point where you’re so frustrated that you just want the person gone.”
Once the physician has identified the problem, the next step — taken as quickly as possible — is to open lines of communication with the underperforming employee.
Communicating the problem
In communicating issues with staff, it’s important to strike a balance between firm supervisor and sympathetic colleague, according to Dr. Bhatia.
“Re-assert your position as the boss. Sit down with them and say, This is what we’re expecting, and these are the deficiencies we’re seeing,’ to try and get them to measurably improve. It doesn’t have to be cold and impersonal, it should just be an assertion of what you need. Don’t make it threatening, but you do want to put a time frame to it — 'in three months, this is what we expect to see.’”
According to dermatologist Clifford W. Lober, MD, JD, a member of the Academy’s Judicial Panel, the criteria that Dr. Bhatia mentioned are the vital core of a performance improvement project. In addition, he said, an employee falling short of the stated duties of the position gives one a chance to analyze the reasonableness of the job duties.
“If someone’s performing poorly, perhaps it’s performance goals being unrealistic, perhaps they don’t have the resources they need to do their job effectively, or perhaps it’s a personal issue. You really want to know from that employee why they might not be achieving the expectations you set,” Dr. Lober said. “Depending on what the stated improvement goals are, you want to give them a time frame for corrective action. It could be a week, it could be a month it depends on what they’re doing poorly. Lastly, you should give written notice so that there’s no question in the future that they’ve been notified of what delinquencies might exist.”[pagebreak]
Though not a legal requirement in most states, Los Angeles attorney Ken Koury, JD, agreed that raising issues with employees is a good time to document the performance adjustment process. In the unlikely event of a termination lawsuit, he said, it helps to have as much documented fact as possible on your side.
“Although it’s not legally required, it’s a great idea to document everything. If you have a file for each employee, if there’s been any kind of a problem, you want to have that documented. If you have to counsel them or give them some kind of warning, you have to have that documented,” Koury said. “If there’s litigation, it’s going to be up to the former employee to show that there was an illegal reason for their termination. Someone told me once that litigation isn’t necessarily about the truth, it isn’t about right or wrong, it’s about what you can sell. If you have the documentation showing you have the right reasons for terminating an employee, you’re most likely going to come out okay.”
During the communications process, Sergay said, physicians can often find the root of an employee’s performance troubles and address immediate corrective action. Doing so can save the employee’s job and the practice’s efficiency. Sometimes, she said, the adverse effect on the employee’s work has nothing to do with their daily duties in the office.
“If you have someone who has consistently been a good performer and suddenly, they’re not performing well, you’ve got to think if it’s something in the workplace or something broader in their lives. You have to allow the other person to contextualize it for you. Ask what happened? This was not the case with your work up to this point. Why are we seeing this now?’ Give the person a chance, and from that point it may make for a much more meaningful discussion,” Sergay said. “There have been incidents in my own work life that fit this. I had a really top performer who was suddenly doing dastardly stuff. It just didn’t make any sense. When I brought him in and started to chat with him, it turned out he was going through a really messy divorce. He’d not told anyone at work, but it was impacting him. We can’t discount that other things are happening in their lives.”[pagebreak]
Dermatologists, Sergay said, don’t necessarily need to offer counsel, and the work at hand won’t go away simply because a manager has discovered the root of the problem. But by indentifying the problem, she said, gives the physician an opportunity to stress to the employee that he or she sympathizes — and also hopes to see the employee’s work improve rapidly. Sometimes, Sergay said, the employee can be moved to a less stressful set of duties for the short term or given a day or two off to collect themselves. If these steps prove impossible, a frank discussion about addressing professional and personal problems at the proper respective times will at least stress the physician’s understanding of the underlying problem and determination to get the employee’s productivity back on track.
Performance improvement planning
When entering into a performance improvement plan, Sergay said, it should be with the conviction that the process will either improve the employee’s performance or result in consequences — anything from minor disciplinary action to termination in severe cases. Goals should be objective and easily measurable. One vital aspect of performance improvement, according to Dr. Bhatia, is evaluating the employee’s improvement in relation to past performance. Doing so, he said, can give the physician a measure of how serious the problem is, and whether an instance of poor performance is the result of an off day or part of a larger pattern.
“In the office setting, it’s easy to follow a staff member’s progress. Say, for example, someone’s not cleaning instruments well. You have a pattern of behavior in place, as well as results you can see — where and how they’re getting cleaned. Use that for quality assurance measurement going forward. If the problem was with bad patient interaction, you set them up for the same kind of patient and say this didn’t go well — let’s see what happens again.’ It sets the distinction between an episode and a pattern,” Dr. Bhatia said. “You try to set up tests not entrap them, but to find a marker of quality assurance. It’s sort of like what you do with other doctors or extenders in the office when you hire someone new — pull their charts and monitor their progress. You can extend the same philosophy with any staff.”
In addition to identifying concrete and measurable performance objectives, Sergay said that it’s also important to look at how the employee performs the processes associated with the position, and examine whether there’s a weak link in the employee’s training or resources that could be corrected. This scenario, she said, allows a practice owner to take a longer-term look at expectations for the position both currently and in the foreseeable future.
“Ask the employee: What do you need to develop or learn to do your job better than we’re currently seeing? Are there any shortfalls?’” Sergay suggested. “We should also ask, Are you good at what you’re doing? How do we make sure that you stay cutting-edge? What further development’s needed?’” Asking these questions, Sergay said, ensures that the focus of the employee development effort is not just for the job as it stands now, but for the job as the practice plans for it to evolve based on its strategy for the future.
By following this process outlined above, Dr. Lober said, it’s entirely possible to retain staff for decades at a time. Dr. Lober’s nurse has been with him for 27 years, and he hasn’t had to let go of any employees in two decades. He said the success he has had with staff retention is in large part attributable to his focus on employee performance and staff morale.
“Of the employees I have right now, none has been with me fewer than 20 years,” Dr. Lober said. “It’s a pleasure not to have to worry. But everyone should know how to deal with employee issues before they can harm your practice.”
Performance management process
In dealing with staff performance in your practice, the dermatologists and experts interviewed recommended a series of steps that stress preparation, quick action, and measurable goals.
1. Create a detailed, specific job description.
The best way to gauge performance is to explicitly list expected and ideal performance. With a well-written job description, employees come in knowing what is expected and agreeing to carry out the duties as the practitioner describes them.
2. When you see a problem, act on it immediately.
The close-knit environment of some smaller practices often leads practice owners to be reticent about confronting employees, according to Dianne Shaddock Austin, founder of consulting group Easy Small Business HR. Waiting for a demonstrated problem to fix itself only increases the chances of it getting worse, she said. Talk to the employee as soon as a performance issue is detected.
3. Create performance goals and measurable objectives.
Create a performance plan for the staff member. Clearly lay out expected performance improvement, set objective goals, and create a timeline for the process. Make explicit the consequences of failing to meet the objectives. Most physicians and management experts suggest a three-month period.
4. Monitor the employee’s progress.
During the performance plan period, it will be necessary to devote more time than usual to auditing the staff member’s performance. The upside, however, is a clear picture of the employee’s capability and improvement by the end of the process.
“In this three month period, it’s going to take quite a bit of time from the manager, whoever that happens to be, because the manager has to keep watching and give feedback,” management consultant Janine Sergay said.
5. Stick to the plan.
At the end of the performance plan period, the physician should have a good idea of the employee’s performance improvement. If he or she has met expectations, the employee can resume his or her duties as before. If not, then it’s important that the physician follow through on the stated consequences.
Despite the best intentions of all involved, sometimes an employee is unable to thrive in the current practice setting. If a performance improvement metric can’t be met, Neal Bhatia, MD, said, it is likely best for the employee involved to part ways with the practice. He said that this decision is often the most agonizing one a practitioner has to make.
“That’s one of the most frustrating aspects of managing a practice — weighing the cost and time of terminating someone and bringing in someone new versus the potential detriment to your practice that keeping an incapable employee can do,” he said. “But if you set out on this three-month plan and by the end of the process you’re still taking a couple hours a week to correct them and coach the employee, and their work hasn’t gotten any more reliable, then it’s not helping anything to keep them at the practice.”
In addition to concerns about job duties, Clifford W. Lober, MD, JD, said that it’s important to define what behaviors will not be tolerated in one’s practice, list them in the employee manual, and note that employees in violation of these rules will be terminated.
“There are certain employee behaviors which can’t be tolerated, such as sexual harassment or theft. There are things for which there has to be zero tolerance,” Dr. Lober said. “One time is one time too many, period.”
Almost equally harmful, Dr. Bhatia said, is a staff member with negative morale. In addition to underperforming, he said, malcontented employees can poison the well by forcing other staff members to worry about their attitude and performance on a daily basis.
“Their morale is destructive. The nickname for that in the office is the staff infection,’ one employee with a bad attitude can become a polarizing influence on the practice,” Dr. Bhatia said. “It gets to the point where no one’s focused on their job, they’re just consumed with interactions with that one person. That really affects job performance, because the focus on efficiency is lost,” he said, and other employees start to have negative feelings about their work situations.
In addition to exhaustively documenting their efforts to improve a departing employee’s performance, Los Angeles attorney Ken Koury, JD, said that employers will often offer a modest severance to head off any potential legal troubles down the road.
“In addition to prevention, another thing that some employers do is offer severance pay in exchange for signing a release promising not to sue. Unless there’s a contract, no one is required to give any kind of severance pay,” Koury said. “But in order to buy peace, they will offer severance pay based on the length of time worked and the signed release. [The employee] waives all claims they have against the employer.”
Though practitioners rightly express concern at the prospect of a lawsuit, Koury said that offering severance is a measure that often serves to cool down the situation. The physician can either broach this topic during the termination conversation, or extend the offer shortly after the employee has had time to process the event — within the week at most.
Most employees, he said, are happy to receive compensation on their way out. The amount offered varies greatly depending on the nature of the termination, the employee’s ending salary, and the length of their tenure with the practice. Those who are already determined to file suit, he said, may accept the settlement — and if they don’t, they were already planning to sue.