Appraisals
Core Components of Effective Appraisals
Written by: Dr Sara Watkin, Medicology Ltd. Published: 3rd June 2010
With revalidation and re-certificationlooming, appraisal has taken on a whole newlevel of importance. However, we are alsoentering a period of danger where appraisalswitches from its core purpose to one ofsimple compliance with recertificationrequirements i.e. appraisal is structuredand undertaken purely as part of the widerprocess of maintaining licensing to practise.The ultimate risk of tick-box appraisalis that we lose a vital component of aneffective performance management system.Conversely though, perhaps we can usethis as an opportunity to establish effectiveappraisal systems that drive enhancedperformance rather than just deal withclinical fitness to practise.
The performance imperative
The healthcare heat has been thoroughlyturned up with many drivers pushing clinicalteams to ever greater levels of performance,against a backdrop of reducing resources.Current pressures include:
- Ever more stringent national targets
- Greater patient expectation over waitingtimes, quality, accessibility etc
- Payment by results, with funding linkeddirectly to productivity
- Reduced man-hours resulting from theEWTD reduction to 48 hour weeks
- Increasing patient numbers arising out ofboth population and disease prevalenceincreases
Failure to perform, which we might defineas dropping the ball on either of qualityor productivity, comes at an ever greatercost to services in the modern, competitiveenvironment. If quality suffers in theinterests of expediency, the Care QualityCommission turns up its own form of heatand the impact of adverse media attentionin the worst cases can wreak havoc with aTrust’s reputation. However, even the highestquality of services remains unsustainable ifthat quality is delivered at the expense offinancial effectiveness (the balance betweenincome and cost). As financial sustainabilityslips, so too does the ability to deliver aquality service.
These are just two of the components ofan effectively performing service, clinicalquality and financial stability; however, thereare many more components to an effectiveservice plan, involving people, patients,promotion and ultimately strategic evolutionin light of the evolving healthcare landscape.Appraisal should serve all of these aspectsof service success if it is to contribute tothe increasing imperative for performanceexcellence.
The true purpose of appraisal
Organisations are typically characterised assystems consisting of a series of inputs (rawmaterials – mostly patients, in our case),processes (what we do with patients) andoutputs (treated patients). All of those relateto the purpose of the organisation, which isusually characterised as a vision with a seriesof strategic and operation goals designed toachieve it. The workforce of the organisationneed tying meaningfully to the direction andpurpose of the organisation and it is this thatconstitutes the true purpose of appraisal.Appraisal is effectively the bridge betweenwhat the organisation is trying to achieveand the people that will achieve it (table 1).Simply put, appraisal ensures that theemployee understands what they are thereto do in the context of what the organisationis trying to achieve and also seeks to identifyanything that either stands in the way ofthat achievement or could be improvedto enhance achievement. It will also dealwith the future, rather than just the hereand now, examining aspirations and futuredevelopment needs.
360 degree appraisal
Adding in a 360 degree approach allowsappraisal to examine one of the greatestblocks to the achievement of organisationalobjectives – the interaction of people,whether this is at a leadership or teamlevel. Professionals are assessed by theirleaders, peers and underlings across arange of factors identified as signifyingeffective leadership or team performance.The challenge with 360 appraisal is one ofobjectivity and true usefulness.
When James feeds back on Bob,anonymously, that Bob is weak in providingdirection, it is just as much a reflection ofwhat James needs as it is a reflection onwhat Bob does. James is really saying thathe needs stronger direction to help him dohis job. However, when Jenny feeds backthat Bob is overly directive, she could wellbe reflecting that she prefers to be allowedfreedom to operate and likes herself to bein charge too. Now we have a problem –the net result is that Bob is just about rightwith direction and he has learned nothingdespite getting it slightly wrong for bothparties. Removing personal bias to increaseobjectivity in 360 degree feedback remainsone of the unsolved bastions of the system.
Most 360 degree systems tend to testan established range of generic factors.However, as organisational contextchanges e.g. an organisation becomes aFoundation Trust, new factors becomeimportant as part of an overall assessmentof an individual’s effectiveness. AFoundation Trust must compete for apatient pool whilst ensuring tight costmanagement. A useful 360 degree systemmight, for instance, test Bob’s propensity tosave money versus waste it or use resourceswithout consideration to the financialimplications. The best possible appraisalsystem will capture the factors contributingto service success and test against thesefactors, allowing the participant and theorganisation to see where development,adaptation or greater insight is needed.
Process aligned with productivity
A key criticism of appraisals is that theytake a disproportionately high amount oftime for the benefit gained. Often appraisalsystems are cumbersome to use, timeconsuming to complete and frustrating inboth function and form. The ideal appraisalprocess is one of complete simplicity touse but with maximum acquisition orassessment of useful information.
An effective appraisal system balancessensitivity with timeliness. After all,a process to analyse and improveproductivity that gets in the way ofproductivity is counter intuitive.Online systems have the functionalpotential to allow easy access, simplified,consistent data acquisition and usefulanalysis with feedback. However, onlinesystems currently available fail many of ourkey tests of effectiveness in that:
- They are frustrating to use
- They do not address businesseffectiveness in the healthcare context
- They are overly simple and genericin what they assess (all of them haveprominent gaps)
- They do not control for personal bias
Essentially, although going some way toproviding some useful information, we areonly likely to get committed engagementin effective appraisal when the appraisalsystems we use genuinely serve both theindividual and the organisation.
Concluding the core components ofeffective appraisal
Considering all of these inherentweaknesses and needs, we get a muchclear picture of the components ofeffective appraisal systems, whether in 360form or otherwise. The key componentswill include:
- Organisational purpose & direction
- Standards and values
- How performance is measured andassessed
- Leadership, teamwork and interpersonaleffectiveness
- Professional competence/ technicalcapability e.g. clinical competence
- Organisational competence e.g. businessappreciation
- Blocks to an individual’s achievement,both personal and organisational
- Training & development needs
- Future aspirations
- Motivation & morale
Although the list is far from comprehensiveor in detail, until we can move appraisaltowards these as baseline criteria foreffective appraisals, we are allowingone of the most powerful techniques inorganisation performance to fall shortof its true potential. If we managed tocreate the Holy Grail of appraisal systems,professionals would value its ability tohelp them be successful and engagementin appraisal would become the acceptednorm rather than reluctant compliance.
