How to Evaluate Employee Performance in a Small/Medium Sized Hospital

Small and medium scale enterprises are the bedrock of any vibrant economy. In 2005, the Central Bank of Nigeria classified industries thus:

Enterprise	No of Employees	Asset Base (Naira)
Micro	</= 10	< 1.5 Million
Small Scale	11-100	</= 50 Million
Medium Scale	101-300	50-200 Million
Large	>300	>200 Million

Using the classification above, many hospitals in Nigeria and the developing world can be categorized as small or medium scale hospitals. Such hospitals usually don’t have a formal method of evaluating employees’ performance neither do they have a structure in place to do that.

It must be noted however that many hospital owners do not evaluate employee performance not because they don’t want to but because they don’t know how to.

This post will teach you how to evaluate your employees using simple criteria. After studying the example below, you can develop criteria that will fit your hospital and expectations.

The first step to performance evaluation is answering the following questions:

What will I evaluate?
The three most important criteria to evaluate include:
• Personal Qualities
• Professional Qualities
• On-the-Job Qualities

Who will do the evaluation?
Evaluation can be conducted by employee (self rating), peers, immediate supervisor, and management. The use of multiple evaluations (i.e. combination of all four) helps to reduce problems of validity and reliability. The ratings from each level of evaluation can be averaged to get the employees final score.

How will it be done?
Methods to use may include written tests, rating system, oral interviews or a combination of all three.

How often will it be done?
Depending on your peculiar needs, performance evaluation may occur biannually, annually, biennially or every 3 years.

What will I do with the outcome?
This may include setting performance improvement goals for employees as well as plans of action to implement them.

What are the consequences for employees who do not meet standards?
Consequences may include placing employees on probation (then reviewing employee performance at the end of the probationary period), training and development, transfer of employee to another unit, demotion of employee or outright termination of appointments for those who refuse to improve.

Finally, you must discuss areas of the performance review including the employee's feedback. Then record the evaluation in the personnel files.

Let’s see how the actual performance evaluation is done using the Rating Method. The criteria I will use are
• Personal Qualities
• Professional Qualities
• On-the-Job Qualities

These are further divided into several sub-criteria and rated on a scale of 1-5 as indicated below.
• 5 = Consistently exceeds expectations
• 4 = Frequently exceeds expectations
• 3 = Achieves/meets expectations
• 2 = Inconsistently meets expectations
• 1 = Performs below expectations

Example
John Ebele is a laboratory scientist working at Demy Hospital. He is due for his annual performance appraisal and the owner of the hospital, Dr. Yahaya rates him on the three criteria of personal qualities, professional qualities and on-the-job qualities as shown below. He scores 10.7 out of a possible 15 points.

NAME	CRITERIA	RATING (1-5)	AVERAGE RATING (max score:5)	TOTAL SCORE(15)
JOHN EBELE	PERSONAL QUALITIES ·        Integrity ·        Diversity ·        Initiative ·        Innovation ·        Respect ·        Growth	·        3 ·        4 ·        5 ·        5 ·        1 ·        4	3.7	10.7
	PROFESSIONAL QUALITIES ·        Interpersonal skills ·        Quality of work ·        Stewardship ·        Reliability ·        Productivity ·        Knowledge	·        2 ·        4 ·        3 ·        3 ·        4 ·        3	3.2
	ON-THE-JOB QUALITIES ·        Duties and Responsibilities ·        Health and Safety ·        Professionalism ·        Efficiency and Effectiveness ·        Continuous Development	·        3 ·        4 ·        4 ·        4 ·        4	3.8

The next step after the evaluation will be to review the rating with the employee.

Using our example, Dr Yahaya will discuss with Mr. Ebele on areas that need improvement. For example, he got a score of 1 in the respect criteria. This obviously has to be improved. The steps to be taken for improvement are discussed and a time frame for the next evaluation is agreed upon by both Dr Yahaya and Mr. Ebele. He may also require training to boost his performance in other areas. This should be determined and implemented as well.

Regular performance evaluation is a must for every serious minded hospital. It is important that you have a thorough knowledge of how to perform evaluations.Kindly go through the example again so you will fully grasp the steps involved.

 I will write on another aspect of HR management in a subsequent post.

See you soon….

7 Reasons Why You Must Evaluate Employee Performance

Evaluating employee performance is the assessment of the employee’s effectiveness in doing the job. Though seemingly tedious, it is a task that you must undertake at regular intervals.

Here are some reasons why you must do a regular performance evaluation or appraisal:

Reason #1: To recognize the training and development needs of employees

Performance appraisal helps you to identify the shortcomings of employees and to recognize the need for their training and development. This knowledge will help you plan development and training programs that will be beneficial to your employees. Without regular appraisals, training will be largely haphazard and add little or no value to your employees.

Reason #2: To determine the extent to which employees contribute to    organizational success

When employees do not reach the standards of performance set, organizational success cannot be achieved. Employee evaluation therefore helps you determine the extent to which each employee meets standards and how much they contribute to your success.

Reason #3: To motivate employees to perform better

When an employee is evaluated and commended for doing well, he/she is motivated to perform better. Those rated poorly during evaluation are also inspired to improve their performance before the next evaluation.

Reason #4: To keep employees on their toes

Another reason why you must evaluate employees’ performance is to keep them on their toes. When employees know that they will be appraised and that their promotion depends on the outcome of their appraisal, they become more committed to their duty.

Reason #5: To develop acceptable behavior in employees

Regular appraisals are one way of identifying deviant behavior. Appraisals help you to not only identify deviant behavior but also to correct such behavior. Thus, employees develop patterns of behavior that are acceptable to your organization.

Reason #6: To foster employee-management relationship

Appraisals usually occur in the form of an interaction between an employee and management (management-oriented appraisal), an employee and supervisor (supervisor-oriented appraisal) or an employee and co-worker (peer-oriented appraisal). The aim of these interactions is to determine performance. Good interactions however, have an additional benefit. They help you to know who the employee really is, understand his/her needs, shortcomings and strengths; thus creating a relationship between you and employees. Regular appraisals strengthen this relationship and foster unity in the workplace.

Reason #7: To identify employees that deserves promotion

Employees deserve to move from one level to another as they progress in their careers. The tendency is to promote employees every 3 years or so. But promoting a redundant employee just because he/she has worked for a certain period of time may be counterproductive. Appraisals will help you identify employees that actually deserve promotion and reduce the chances of promoting redundant employees.

From the reasons above, it is clear that you must regularly evaluate the performance of your employees to achieve business success.

When evaluating performance, the three most important criteria to use are:

• ·        Personal Qualities
• ·        Professional Qualities
• ·        On-the-Job Qualities

In my next post, I will show you how to carry outperformance appraisal using these criteria.

See you soon…..

How to Determine the Optimal Target Manpower for Your Hospital

There are many methods used by Operation Management Experts to determine the number of employees needed by an organization. The two common ones are the Full Time Equivalent (FTE) method and the Takt time Method. In my Training Sessions with Hospital Entrepreneurs, Doctors and Managers, I tend to favor the Takt time method. Though slightly more technical, it can be used in combination with deductive reasoning. This makes it suitable for use in the hospital setting. Physicians are generally not fans of calculations, so I will explain it as clearly as I can.

 Firstly, I will define the following terms-Labor Content, Demand, Takt Time and Target Manpower.

Labor content is the total amount of time that a flow unit (e.g. a patient) spends within a process. It is determined by calculating the sum of the individual time each resource/employee spent with the patient. For example, if a patient spends 5 mins at registration, 30 mins at consultation and 30 mins at the pharmacy before leaving the hospital, the labor content will be (5 mins+30 mins+30 mins) 65 mins.

The demand is the total number of flow units per given period. E.g. we can speak of a demand of 10 patients/hour.

The takt time defines the ideal amount of time that a flow unit should spend with each resource/employee/work station. Takt is a German word that means “the beat of the music”. Literally, it signifies that workers should dance to the beat of the music of demand. That is, if the demand increases, the pace of the work should also increase. If the demand reduces, then the work pace should equally drop. The formula for Takt time is:

Takt Time= 1/Demand

           Or

Takt Time/hour= 60 mins/Demand per hour

 The target manpower is the approximate number of resources you need to employ in order to achieve the takt time. It is calculated as follows:

Target Manpower = Labor Content/Takt time

For better understanding, let’s consider the problem below:

Dr. Johnson is a Hospital Entrepreneur who owns a modest hospital, New-life Hospital (a general practice facility) located in a small town. He runs consultation services Mon-Fri (8 am-4 pm) and also admits the occasional patient into the ward. Thus the hospital is open 24 hours a day, 365 days a year.

He has on his payroll, 1 resident doctor, 9 nurses who rotate on an 8 hourly basis. (3 nurses on morning shift, 2 on afternoon, and 2 on night duty and 2 off duty). He also employs 1 pharmacist-technician, 1 laboratory scientist, and 1 receptionist/records staff to help him during clinic hours (8 am-4 pm). His total number of employees is 13.

His workers are idle most of the time except on Wednesdays (ANC days) when the demand is overwhelming (40 patients on average). During ANC days, the workers usually work overtime. The ANC process is as follows: 5 mins (registration), 10 mins (vital signs), 15 mins (doctor) 30 mins (laboratory) and 20 mins (pharmacy).

On other days, New-life hospital attends to an average of 16 patients in the Out-Patient Clinic.

What should be his optimal target manpower for Non-ANC days and for ANC days? (Assume a labor content of 40mins during non-ANC days.)

Solution:-

To calculate the target manpower for non-ANC days ,

Labor content =40 mins (given above)

Demand/hour = 16 patients/8 hours

                         = 2 patients/hour

 (Note that there are 8 working hours every clinic day and a total of 16 patients every clinic day)

Takt Time/hour = 60/Demand per hour

= 60/2= 30 mins (i.e. a patient should spend 30 minutes at each work station)

Target Manpower = Labor Content/Takt Time

                                 =40/30= 1.3   (approx. 2 workers)

N.B: In practice, a patient will not spend an equal amount of time at each work station. The 30 minutes above is therefore a theoretical guide that gives the maximum duration a patient should spend with each resource at New-Life Hospital.

Let’s calculate these same values for ANC days

Labor Content = 5 mins+10 mins+15 mins+30 mins+20 mins

                          = 80 minutes

Demand/hour = 40/8

                          = 5patients/hour

Takt Time/hour = 60/5

= 12 mins (i.e. a patient can spend 12 minutes at each work station)

Target Manpower = 80/12

                                = 6.7 (approx. 7 workers)

Deductions:

1.     For non-ANC days, the target manpower is actually 1.3 workers. However, we rounded it up to 2 workers because we can’t have 0.3 of a person. But having only 2 workers in a clinic is hardly practicable (unless, Dr. Johnson wants to run a village health outpost).

Dr Johnson feels that to effectively run a clinic, there must be a minimum of a doctor, a nurse, a pharmacist-technician and a laboratory scientist. That makes a total of at least 4 workers. Dr. Johnson currently has 9 nurses, 1 doctor, 1 pharmacist-technician, 1 laboratory scientist and 1 record staff making a total of 13 workers.

To determine his optimal target manpower for Non-ANC days, I will assume here that the number of patients visiting the OPD daily determines the number of patients on admission. If only 2 patients come every hour, the chances are that the admission rate will be low, therefore the nurses on afternoon and night shifts will not have much to do.

With that in mind, Dr. Johnson doesn’t need a resident doctor on non-ANC days. He alone can cope with the work load until his clientele increases. He also doesn’t need a records staff, 1 of his nurses can perform that role currently. Also, he doesn’t need 9 nurses. 5 nurses should suffice i.e. 2 on morning shift, 1 on afternoon, 1 at night and 1 on off duty per time.

 The optimal target manpower for non-ANC days will now consist of 5 nurses, 1 laboratory scientist, and 1 pharmacist-technician = 7 workers.

(We arrived at this number through a combination of scientific calculations and deductive reasoning.)

2.     On ANC days, the demand increases to 5 patients/hour and the calculated target manpower is 7 workers (not 6.7 because you can’t have 0.7 of a person). This corresponds with the optimal target manpower for non-ANC days.

However, because of the increased work load on ANC days, Dr Johnson may need to employ a Doctor on a part time basis and also bring in an extra nurse. This will bring the optimal target manpower on ANC days to 9.

3.       Finally, from calculations and deductive reasoning, Dr Johnson should employ 7 full time employees and 2 part-time employees. This brings his total number of employees to 9 instead of 12.  This 9 should consist of 5 full-time nurses, 1 full-time laboratory scientist, 1 full-time pharmacist-technician, 1 part-time nurse and 1 part-time doctor. 

Do You Have Oxygen?

Today, I will like to share two stories with you. Please read on:

Courtesy: Wikipedia

1.

On Wednesday June 24^th, I was called out of a church service by a well respected High Court Judge. He wanted me to help take a look at a little girl. Diane (not her real name) was a sweet looking two-year old. What struck me when I first saw her was how frail she was. She clearly had growth retardation and was about half her expected weight. She was in severe respiratory distress, cyanosed and febrile. Her parents said she had being admitted about 5 different times since birth for ‘pneumonia’. I didn’t have a stethoscope to listen to her heart. But, I immediately thought of a congenital heart disease.

I placed a call to a very good friend who is a Pediatric Resident and sent Diane to him for evaluation and management. After examination at the hospital where he works, he confirmed my fears. She had a Congenital Heart Disease. He promptly proceeded to admit her into the ward prior to investigations and further review. But alas, the oxygen cylinder in the ward was empty! And there was no oxygen in the entire hospital. Since her condition required oxygen as part of the immediate management, Diane was referred to another hospital. She died as soon as she got to the entrance of the emergency pediatric unit of the second hospital!

2.

About two years ago, a very close relative suffered a CVA and was admitted into the medical ward of a hospital. He was comatose for about a week and in that period, he needed oxygen to remain alive. The hospital didn’t have enough to go round all the patients. I wanted to keep him alive long enough so all his children could come visit him before his imminent death. As a result, I had to ‘borrow’ oxygen from several private hospitals in town to supplement what the hospital could spare for him.

The stories above are not fictional. They are real stories that involved real people who needed something as basic as oxygen. I am sure similar scenarios play out daily in hospitals and clinics all over the developing world. I have seen so-called emergency ambulances used to convey critically ill patients that lacked oxygen canisters/cylinders! Sadly, what Physicians in developed countries take for granted is now a luxury in many developing countries like mine. There is an urgent need to restructure and revamp the healthcare system in developing countries. We must put in place an organized system to prevent the absence or shortage of vital materials and equipment.

Oxygen alone certainly cannot treat all illnesses and diseases. Diane probably would have died even if she had received oxygen. My close relative also died despite my best efforts to provide oxygen. But that is beside the point.

The simple question is: Do you have oxygen and other basic live-saving equipment in your hospital?

It could mean the difference between life and death. If you currently lack oxygen and other basic life-saving equipment in your hospital, the time to get it is NOW! You would be saving lives.

Cheers!

Who Are Your Customers?

There are two basic questions I always ask in my Customer Care Training Workshops. The first is “who are your customers”? I get various responses like; “my customers are my patients”, or “customers are those who buy services from us”. Then I ask the next question, “who is a consumer”? At this stage, a lot of people get stumped and ask “aren’t they the same”? Well, not really.

Your customer is someone who purchases a product (a service or a good) from you. The customer may not necessarily purchase the product for personal use or satisfaction.  A customer is also a person with whom you have dealings. A consumer on the other hand, is a person who actually uses your product and derives personal satisfaction from it.

In this context, a customer could be a Medical Insurance Company or a Health Management Organization (HMO) that purchases health insurance for a group of employees. The employees are the consumers. A customer could also be a parent who pays the dentist to do scaling and polishing for his daughter. In this case, the daughter is the consumer and the parent is the customer. A person who presents in the ER and pays for his treatment is both a customer and a consumer.

You must ensure you identify both the customer and the consumer in each case and provide the service that each needs. The consumer needs good health, while the customer expects value for money. Satisfying both is always a delicate balancing act. This is especially true with regard to Medical Insurance Companies and HMOs. Excellent service involves satisfying both the customer and the consumer.  However, the ultimate person is the consumer, who is the patient.

To satisfy the consumer, you need to understand the concept of the customer chain. But first, let us consider the various classes of customers encountered in a typical hospital:

• —  External Customers
• Internal Customers
• Corporate Customers
• Regulatory Customers

The external customers come from outside the hospital environment. They are the most important component in the customer chain. The external customer includes the patient, his/her relatives and friends. They require the services of the hospital. External customers can be both customers (purchase the service) and consumers (derive personal satisfaction from using the service).

The internal customers come from within the hospital environment. They include doctors, pharmacists, hospital administrators etc. They require the service of another service provider to perform their own duties. Internal customers are mainly consumers. They use/consume the services of others.

Corporate customers are also from the external environment. They differ from external customers because they do not consume hospital services. Rather, they provide service to the hospital. Examples are suppliers, pharmaceutical company sales reps, waste disposal companies etc. Without your corporate customers, you may not be able to meet the needs of your external customers.

Finally, the regulatory bodies monitor the activities of the hospital to ensure minimum standards of healthcare quality are met.

The Customer Chain

These different types of customers form a chain called the customer chain. The chain begins when the corporate customers supply drugs, consumables and other services to the hospital. The quality of service received from the corporate customers influences the quality of service the hospital will provide to its other classes of customers.

The customer chain continues when the external customer/consumer/patient requires treatment and presents at the hospital. The internal customers then ‘processes’ the patient through the hospital system.

For example, the front desk provides a service to the doctor by pulling out the relevant documents pertaining to the particular patient. The doctor also requires the service of the laboratory scientist to aid the diagnosis. He in turn provides service to the laboratory by requesting for the right investigation. The nurse is expected to carry out the instructions of the doctors.

The regulators ensure that all that takes place is acceptable and legal. The chain goes on to the last point of service the patient comes across before exiting the hospital.

If one person in this chain does a shoddy job, the customer leaves with an unsatisfactory service. A break in this chain leads to poor service. Shoddiness can result from misdiagnosis, wrong tests results, expired drugs, poorly filled prescriptions e.t.c.

Excellent customer service therefore begins from identifying your customers and consumers; ensuring each member of the medical team understands the customer chain and their position in it; and encouraging everyone to give their best at their respective work stations.

See you soon…..

Using Checklist to Improve Hospital Services

I must really apologize that I did not write this post as I had earlier promised. I have been on the road and it has really being hectic. 

However, here is my take on using checklists in healthcare settings.

A checklist is a list of items or points for consideration and action. Like its name, a checklist may be a list of things to check before you do something. A common example of a checklist is the aviation pre-flight checklist used by pilots. Before taking off, there is a list of things that every pilot must do regardless of his/her level of experience. This is done all the time. The purpose is to ensure that the plane is functioning properly before take-off and to prevent any future air mishap.

There are different types of checklists used in medicine. These include:

• ·        Procedure Checklist e.g. Surgical Checklist

• ·        Diagnostic Checklist e.g. Algorithms

• ·        Equipment Checklist e.g. Medical Equipment Checklist

• ·        Iterative Checklist e.g. Protocol for Monitoring Post-Op Patients

It is sad to note that a lot of errors take place in the healthcare industry on a daily basis; wrong surgeries are performed, wrong medication given e.t.c. Majority of these errors arise from lapses in concentration, distractions, or fatigue. Some are quite preventable.

In a recent discussion with a female physician, she said something like “we are doing quite well without checklists. Checklists will just add to the current paperwork burden that we have”.

 Before you nod your head in agreement, please consider the following:

• ·         Firstly, human beings are not infallible. Distractions, fatigue and concentration lapses lead to variability in service delivery. Variability leads to mistakes and mistakes can lead to severe disability or death (What physicians like to call iatrogenic). With the use of checklists, the hospital system is strengthened, peer review and assessment enhanced and variability reduced.

• ·        Secondly, you cannot remember everything or commit everything to memory. I am sure you can recall several instances that you forgot a critical step or item in a procedure. Using a checklist will make sure you don’t forget a thing. You become almost infallible.

• ·        Thirdly, different people follow different steps to perform the same procedure. Some steps may be necessary and correct; others may be unnecessary and incorrect. This results in a waste of time, resources, efforts or skills. This also causes variability which is an enemy of quality service. A checklist will thus help to standardize procedures, reduce waste, eliminate variability and improve quality.

I will illustrate with the case study below:

Dr. Wright is in the OR performing an elective C-section on Mrs. Gabo, a 42 year old primigravida. He has already extracted a 4.5kg male neonate. In the process, there is a deep tear extending from the anterior part of the lower uterine segment towards the posterior surface of the urinary bladder. In an attempt to close the uterus beginning at this “angle of sorrow”, the suture snaps. The scrub nurse is so jittery that he drops the replacement on the floor. That happens to be the last Chromic 2 suture available in the hospital. The only other available chromic suture is a Chromic 2/0. Dr Wright struggles and fumbles to use this to repair the tear. Unfortunately, Mrs. Gabo continues bleeding and eventually dies from severe hemorrhage.

A simple procedure checklist used at the beginning of the surgery could have prevented this death. An equipment checklist used before the commencement of the surgery could also have revealed the inadequate quantity of relevant sutures.  

The World Health Organization (WHO) developed a simple surgical safety checklist some years ago. This can be adapted and modified to suit local conditions. You can see it here.

Before developing any kind of checklist for your hospital, it is important you determine first and foremost the purpose of the checklist. What is the checklist meant to do specifically? 

Next, decide on the type of checklist that is needed to fulfill the given objective i.e. a procedure checklist, equipment checklist e.t.c.

Another important step in developing checklists is to involve the group of people to use the checklist in a brainstorming session. This group should also include experts/specialists in the area of need. Several different ideas may be considered during development. A checklist that is acceptable to all concerned should be the product of this session.

Of course, you also need to set benchmarks to help you determine the effectiveness of the checklist. This will enable you review the checklist periodically to ensure it remains relevant to your practice.

Please note that a checklist is as important in a private hospital as it is in a public hospital.

They should be a necessary part of any hospital. 

Thanks for reading. See you soon….