You are reviewing the performance of the department as a whole. Within your department there are widespread calls for accountability. How do you achieve accountability without disenfranchising your staff?

While goodwill and desire drives performance, there must still be accountability for job performance. This may be at an individual or a group level. Accountability requires both an articulation of the specific expectations, and a mechanism to reconcile against those expectations. When expectations are vague, it will be difficult to determine if they have been met.

Accountability at an individual level requires performance management (see my previous post on Performance Management here), whereas performance at a group level requires group accountability (see also Laying the Groundwork). An important step in group accountability is to develop a set of appraisal measures (also known as KPI or key performance indications). The measures must be cogent, easily accessible, and consider the important activities. The challenge for KPIs is to identify measures that evaluate both the quantity and quality of the activity. For example, for a group of surgeons an accountability report might include:

1. Clinical – quantity (OR hours, inpatient days, and outpatient visits); quality (patient satisfaction, patient-reported outcomes or surgical infection rates)
2. Research – quantity (the number of publication); quality (impact factor)
3. Teaching – quantity (teaching days); quality (teaching effectiveness scores)

Activity should be aggregated by groups, and reported by full time equivalents (FTE). Any measures used also need to be prorated by percentage of time spent in the respective activities. For example, presume you lead a department with four divisions of different sizes. You would use measures of clinical activities relevant to all four groups. But because the groups are of different sizes, the reports of activity would be prorated by the numbers of individuals engaged full time in each activity.

Measures of group performance should be shared widely. While individual performance should also be measured, it should not be widely shared. Like group activity, individual productivity will vary based on job activity profiles, i.e. percentage of time spent in clinical care, teaching and research. Reports should be generated regularly with trending. It is important that division/department leaders receive a report that includes individual productivity measures within their respective division/department. As discussed in my previous post on Performance Management, poor performance must be addressed. The general principal is to share group aggregated results within the group, but deal with individual issues individually. An important issue in evaluating individual performance is to recognize that not everyone produces at the highest levels. The decision of how to decide if an individual is underperforming is complex. Also, not everyone will excel in all spheres. For example, some individuals do not have the ability or interest to perform research.

While KPIs are a useful tool for performance accountability and evaluating change, there are several issues. One of the challenges of an accountability report is comparing data within division/departments, e.g. for surgeons, how does the number of outpatient visits relate to OR hours? Also, different activities and specialities vary in time required for specific tasks, i.e. a pre-perioperative discussion for a tumour surgeon will require much more time compared to a fracture patient. Additionally, time spent does not necessarily reflect productivity or efficiency. For example, an inefficient surgeon compared to an efficient surgeon may take more time per case and end up with more OR hours but actually be less productive. While average case times or clinic times may help, different case complexity will complicate comparisons. The leader must accept that no measure is perfect, therefore it can provide only general impressions.

Another issue is whether to tie productivity to pay. As I have noted previously in my Incentivizing Performance post, productivity has been shown to be more closely tied to inspirational motivation than remuneration. Peer pressure is a powerful force; and thus, providing accountability data may help change behaviour. Also, pay for performance programs are difficult and expensive to create. Time will tell whether pay for performance leads to sufficient change to justify the cost.

Accountability will not be exhaustive for all activity given the effort and complexity of accurately collecting data. Given the results will not reflect full scope of activity for some individuals and groups, there needs to be an opportunity for those who appear to underperform to provide mitigation or context.

In summary, accountability for productivity at a group level is essential. Accountability requires developing cogent and accurate measures that measure the main spheres of activity, recognizing that not all activities can be measured, not all activities are comparable, and not everyone performs at the highest level.