Employee appraisals, generally part of a larger performance management (PM) system, are believed to be one of the most difficult responsibilities assumed by managers, and it is estimated that 20% of all employee appraisals are effective in accomplishing their intended purpose (as cited in Savage and Khatri, p. 235). Yet, healthcare organizations (HCOs) persist in developing PM systems that require that clinical unit managers, who often have a span of control of 100 or more employees working 24/7, complete appraisals on a yearly basis and monitor their employees' performance. In developing these systems, HCOs are addressing one of Accreditation Canada's (2014) leadership standards that include "allocating resources and building infrastructure, managing resources, working with partners to share and optimize resources fairly in accordance with organizational priorities, human resource and PM systems …"

Given the characteristics of HCOs, the PM systems we've developed require a second look. HCOs have a relatively flat structure and broad spans of control, characteristics that differ from other organizations. The importance of context in the development of these systems has been emphasized in the research literature. Examples of context include organizational characteristics; organizational culture, e.g., coach (focus on motivation) versus judge (focus on outcomes); economic conditions; legal climate; strategy; performance (financial and quality); and norms, including, for example, the valuing of feedback (Levy and Williams, 2004). Contextual elements that may affect the middle managers' ability to carry out their role in PM include their perception of conflicting goals, including accountability for efficiently managing human and financial resources and quality of care. Frequently these goals are not aligned in the organization (Lemieux-Charles et al. 2003).

We argue that the development of competencies and clarifying performance expectations is necessary; however, feedback given on a yearly basis without follow-up, coaching and mentorship will not modify behaviour. We propose that current staffing models force HCOs to reframe the way in which they should think about PM and offer an opportunity to re-cast PM as a process that values clinicians as self-managing professionals. In this paradigm, employees take responsibility for their own performance, while management's role is to provide the tools to support employees to develop themselves.

In 2013, Berwick published a report, commissioned by the National Health Service in England, following a series of high-profile quality-of-care concerns. Among the recommendations aimed at all levels of government, HCO leaders, staff, patients and carers, he recommended that leaders and managers actively support staff through excellent human resource practices including providing staff with helpful feedback and recognizing system problems; making sure staff feel safe, supported, respected and valued at work; and applying sanctions to the wilful neglect and/or mistreatment of patients (pp. 36–45). Such recommendations are not new; however, he also stressed the need to acknowledge that HCOs are learning systems.

A learning organization takes into account the knowledge and skills that reside within its employees, their relationships with colleagues and clients and the culture of inquiry that has been created (Virani et al. 2012). The importance of relationships to learning has recently been highlighted in two different literature streams.

First, a recent review of Learning in the 21st Century Workplace (Noe, Clarke, Klein 2014) highlights Bear et al.'s (2008) estimate that informal learning accounts for up to 75% of learning within organizations. Such informal learning includes learning from oneself through self-reflection; learning from others such as peers, supervisors and mentors; and learning from such activities as reading print or online material.

Second, Oldham and Hackman (2010), well-known for their seminal work in the areas of job design and teams, reflect on the fact that the study of work going forward will need to take into account its social dimension, which contributes to motivation, performance and well-being. They observe that social interaction is much more pervasive and prominent today than when they began their studies 30 years ago. In the service sectors, employees are expected to interact frequently with their co-workers and with clients. They imagine that when considering the organization's context, there may be opportunities to learn from the front line and consider increasing the flexibility of jobs based on employees' assessment of the work. Their view is that "such an idea would have been deemed pure fantasy when we wrote our book on Work Redesign in 1980" (p. 473).

If employees are more connected than ever before and are continually learning from one another, how do we build in ongoing feedback and sharing mechanisms that address their learning needs and provide them with performance feedback? Berwick recommends that "the systems should be simple and clear; avoid diffusion of responsibility; respectful of the goodwill and sound intention of the majority of staff." He also emphasizes that incentives should be congruent with the overall vision and mission of the HCO. Front-line staff need to see and understand the connection between strategic decisions and their lived reality.

We are not recommending that work on present PM systems be discarded. However, we suggest that an industrial-type model of yearly conversations to complete forms without ongoing interactions and feedback will fail. What options should we consider?

In clinical settings, accountability for performance appraisals usually lies with the patient care unit manager. Nagle (2011) has challenged HCOs to create management roles that are more manageable and truly nurturing of the leadership they want to encourage. Questions regarding whether we have sufficient numbers of people actively engaged, and ready and able to take action at the front lines abound (Baker 2013). Though these questions more often arise in relation to the QI agenda, quality and the business of healthcare are two sides of the same coin.

Another option is to reconsider the supports required by patient care managers if they are to remain directly accountable for the performance of staff within their units. No other industry's managers have the same span of control as seen in HCOs. To speak of leadership and its importance without acknowledging the challenges faced by this group is unfair. McCutcheon et al. (2009) demonstrated that even managers who were considered transformational leaders were unable to enact these skills when faced with accountability for large numbers of staff, and Wong et al. (2014) recently described the concerns of front-line managers regarding their ability to manage large spans of control.

Some HCOs have added experts on patient care units such as advanced nurse practitioners, clinical leaders and educational consultants, all of whom are experts in specific domains. Developing novel ways of transferring knowledge through face-to-face or technology-mediated interactions with such experts is one approach. Another is to examine all the sources of knowledge that presently exist in the organization (Virani et al., 2012). For example, the use of information systems to capture the competencies of current staff is another approach to understanding the stock of knowledge available. If learning becomes "our approach to work," then individuals experiencing difficulties will not hesitate to ask for help. Individual and interdisciplinary team feedback through posting of outcome indicators, discussions regarding their meaning and their connection to the HCO's scorecard is essential. Once expectations are clear, electronic forms completed by both staff and manager will also facilitate the process.

Is there a way of formalizing feedback? Some might argue that in unionized settings, it doesn't really matter at the end of the day. However, it does matter to the employee who values his/her work and its quality and to the employer whose pact with the community is safe care. Berwick (2013) has emphasized that we must believe that our staff are well-intentioned and have developed systems and processes to identify where problems may exist.

About the Author

Louise Lemieux-Charles is Professor Emeritus with the Institute of Health Policy, Management and Evaluation at the University of Toronto.

Moshe Greengarten is Associate Director, Hay Group Health Care Consulting based in Toronto.

References

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