In your department, there are leaders who report to you. Many have been leaders for a long time. Several of the groups are restless for change and others have longstanding disagreements among members. How do you gain an understanding of how well the leaders and/or groups are functioning?

This post deals with how to evaluate leaders and the groups they lead. Several principles govern this process. First, rather than finding fault, reviews are a process to evaluate the current status, to identify challenges, including the leadership of a division/department and, perhaps more importantly, to celebrate their accomplishments. Second, reviews encompass not only the success of the leader, but also the entire division/department. Leaders can never be appraised independently of the group and context in which they lead. Third, the review process is intended to position the division/department for future success. Fourth, while not the prime focus, a review provides an explicit opportunity to decide whether to continue with the incumbent leadership and a mechanism, if needed, to change leadership.

Before discussing how to renew leaders, one issue that always comes up is whether leaders’ appointments should be indefinite or term? Term limits for leadership positions may be fixed or renewable fixed duration. The main advantage of term limits is the potential for leadership renewal and an opportunity for new direction. The main disadvantage of term limits is that it may cause the premature truncation of the tenure of a successful leader. My view is that renewable term limits are best. But irrespective of whether term limits are in place, clinical leaders should probably be reviewed every five years or so. Even for institutions without term limits, these reviews serve as an opportunity to renew the strategic direction of the group. For institutions with renewable terms, after the first five years, provided the review is satisfactory, the incumbent can be provided additional five-year terms. Ten years is probably a reasonable time to accomplish many leadership goals, and after ten years many leaders voluntarily choose to relinquish their leadership.

So, if you decide to conduct reviews, what are the steps? What follows is a highly detailed and specific process, as are the approaches to reviews and searches. That’s not to say that this is the only way to manage the review process, but I strongly encourage clinical leaders to prepare a comprehensive plan in order to keep the review on track and working effectively.

The first step in the review process is to have the incumbent prepare a report using a standard template, that i) summarizes the accomplishments of the leader and those of the divisional/department in all spheres of activity, ii) discusses current and future challenges, and iii) articulates goals for the next five years. This report should be a public document created with the help of members of the division/department and should celebrate and acknowledge the accomplishments of the division/department. Any confidential or sensitive material is generally reserved for the meeting between the incumbent and the review committee to be discussed below.

An early step is to assemble a review committee. Membership of the committee should include representatives from the hospital (and university, if relevant), another divisional/departmental leader from within the hospital, possibly a divisional/departmental leader from another hospital, a divisional/departmental representative, a representative of the Medical Staff Association, and for academic health sciences centres, a representative from research and a trainee to address issues related to research and education, respectively.

The review process is enhanced by having reviewer(s) external to the institution. The criteria for choosing an external reviewer includes having an individual of sufficient clinical accomplishment able to evaluate the division/department, having had leadership experience, and having familiarity with the health system and/or hospital. While no external reviewer will fulfil all criteria perfectly, the key issues facing the division/department are crucial in making the choice of an appropriate external reviewer.

The chair of the review committee early in the process meets with the division/department members with or without the incumbent (according to the incumbent’s preference). The purpose of this meeting is not to seek feedback or discuss divisional or departmental issues, but explain the review process, reiterate the principles of the review (as noted above), to seek nominations for the external reviewer(s), and to seek nominations for a divisional/departmental representative on review committee from among the members of the department (with expectation that the chosen individual not see themselves as a candidate if a search for a successor is needed).

At the first meeting of the review committee, the chair advises the committee of the process, the purpose of the review, clarifies that the review committee is advisory to the chair, and discusses potential candidates for the external reviewer(s). The number of external reviewers vary depending on the scope of the review and the needed expertise. Finally, confidentiality and conflict of interest (COI) is emphasized, including a requirement that all committee members sign a covenant that COIs have been declared, and that all proceedings and discussions of the committee will be strictly confidential.

The next meeting of the review committee is with the incumbent to discuss their written report. The incumbent’s report is provided to the committee in advance. Generally, the incumbent provides a brief presentation (without slides) followed by questions from the committee for about one hour. The hour is followed by discussion between the chair and the committee to discuss specific issues for the upcoming external review.

In advance of their visit, the external reviewer(s) receives an invitation letter from the chair describing the process of the review, the incumbent’s report, the membership of the review committee, the annual report of the hospital, strategic directions of the hospital with its mission, values and vision, the job description for the leader of the division/department, an itinerary and general terms of reference for the review including any specific issues that have arisen in discussion with the review committee.

The next committee meeting is with the external reviewer(s). While tempting to have the incumbent present their report on the same day as the external review, presentations should be separated for two reasons. Firstly, the meeting with the incumbent, as noted above, may raise issues that need to be addressed by the external reviewer during their visit. Secondly, the presence of the external reviewer on site and the inevitable feedback to the incumbent from the external reviewer during their visit may adversely affect the incumbent’s presentation to the review committee.

The chair of the review committee should meet with the external reviewer at the beginning of the visit to answer any specific questions and to make sure the reviewer understands the process and their task. It is useful to share pictures and cell phone numbers of the chair and reviewer to minimize failure to connect for this initial meeting. The reviewer meets with the members of the review committee individually, other key members of the hospital (and university, if relevant), has lunch with a group of residents and fellows, and has a group meeting with the division/department members supplemented by individual meetings or phone calls as needed. The incumbent also usually has lunch with and/or provides a tour of the facilities, for the reviewer. The external review generally requires 2 days.

One effective way to gain candid feedback is to arrange a dinner on the first evening of the visit between the external reviewer and the chair of the review committee (possibly including senior hospital leadership), to hear initial impressions and answer questions. The next day, just prior to meeting with review committee and after the external reviewer has had all their meetings, the chair meets with the external reviewer to get a brief summary of presentation. This meeting is important to ensure the reviewer is not completely off base with their comments. Thereafter, the reviewer meets with the review committee to provide a brief overview followed by questions and answers for approximately one hour.

The reviewer is instructed to provide a written report within several weeks of their visit. Reimbursement for hotel and travel and the honorarium (usually in the order of $1,000/day) is withheld until the report is received. Under separate cover, the external reviewer provides a recommendation regarding reappointment of the incumbent (if the incumbent is seeking an additional term). Because the written review report usually takes several weeks, immediately after the external review visit, the chair should call the incumbent to provide high-level details of review.

After the written external review has arrived, the report is provided confidentially to the incumbent. The incumbent responds to the reviewer’s comments, but only to correct factual errors and not to refute the external reviewer’s report. The external review and incumbent’s response (on factual content) is provided to the review committee members confidentiality. There is enormous interest about the external reviewer’s report to everyone outside the review committee. Ideally the report is kept confidential out of respect for the incumbent and more importantly to allow the external reviewer to be candid in their comments. One strategy to keep the contents confidential is to make the report accessible for review only by visiting a specific secure location; photocopying the report is prohibited. If need be, the review committee can meet one final time to review the entire process including the external reviewer’s report. Finally, if indicated and desired, the incumbent can then be appointed to an additional term. If a reappointment is not made, then the search process is initiated (see post on Recruiting New Leaders).

As a final step in the review process, the chair of the review committee meets with the division/department members to provide salient aspects of the review and, if appropriate, to explain the search process and to seek nominations of candidates for new leadership.

In conclusion, a review process can provide an arm’s length evaluation of a leader and a group, and provide a means for renewal of direction and possibly leadership.