By Marty Martin, PsyD, MPH, MA
Imagine a patient who walks into an urgent-care center feeling as many patients do – sick, tired, and irritable.
But as soon as the patient arrives, the receptionist greets him warmly and with respect. As the patient sits down in the waiting room, the receptionist lets him know how long the wait might be. When the receptionist invites the man back to the treatment area, he is greeted warmly again, this time by a nurse who expresses sympathy for his illness.

After taking his vital signs, the nurse tells the patient about how long it will be before the physician or healthcare provider comes to see him. The doctor knocks before entering the treatment room, then identifies herself by name and role, establishes eye-contact facing the patient, and then proceeds to elicit the chief complaint and begin the diagnostic process. The doctor leaves the room after asking if the patient has questions and explaining what the next steps in his treatment will be.

Meanwhile, outside the treatment room, the medical staff is working to coordinate the patient’s care. The interactions between the diverse urgent care center staff are factual, professional, and respectful. The non-verbal messages are aligned with the verbal messages. The tone is clear and coherent. Even an occasional difference of opinion is expressed in a spirit of seeking to understand rather, than to confront.

Everyone clearly understands that working together will provide this patient and others with the most high-quality, effective, and satisfying healthcare. Soon, the doctor returns to the treatment room and begins to treat the patient. After the treatment process, the discharge instructions are explained in an easy-to-understand way that matches the patient’s learning style. Before she says good-bye to the patient, the doctor double-checks to make sure all his questions are answered.

The patient checks out at the reception desk, where the staff is courteous and helpful as they take care of any outstanding billing, pharmacy, or scheduling matters. As the patient walks away, they thank him for choosing this urgent care center and bid him farewell.

Once the patient recovers, he keeps telling friends and coworkers that finding a new healthcare provider was the one good thing about getting sick.  “They really did a great job at that urgent care center,” he tells them. “They were competent, confident, professional, and respectful.”

Managing Employee Performance: A Matter of Chance or Design?
Did this patient’s successful visit to the urgent care center happen by chance or by design? Of course, it happened by design, facilitated by a staff of high-performing professionals.  What follows is a road map to creating and sustaining experiences like the one described above. Employee performance can be carefully shaped to provide a satisfying, high-performance climate for employees and a satisfying, highly effective experience for patients.

This journey of managing employee performance to achieve business and clinical excellence begins with leaders asking themselves this question: How can I help each employee fully contribute to the goals of the urgent care center?

Academic researchers and organizational consultants, such as The Gallup Organization, have discovered that the key to aligning employee performance with excellence is promoting employee engagement.

Managing Employee Performance: Engagement Makes the Difference
So, just what is employee engagement? It is the personal connection that employees have to their job, the urgent care center, the manager, or the team that motivates them to excel at their work. Fundamentally, all of your employees are volunteers, even if they are on the payroll.

What does this mean? Each member of your staff has the option of simply doing enough at work to not get fired. However, you cannot operate an effective urgent care center with the bulk of your staff doing just enough to simply keep their jobs. You need staff that will go above and beyond the minimal expectations. Your patients need staffers who push beyond the minimum and always come to work seeking excellence.

Managing Employee Performance along the Continuum
The major task before you as a leader is how to move your employees from marginal performance to acceptable performance and then on to excellent performance.

Set a performance target for each employee. Realize that different staffers will have varying performance targets, ranging from acceptable to excellent. It goes without saying that marginal performance is not a realistic performance target, unless you want your business to fail.

To achieve a maximum return on your investment in managing employee performance along the continuum, remember that the fruits of your labor are greater if you seek to move a staff member from acceptable to excellent performance, rather than from marginal to acceptable performance. Both need to be done, but if you have limited time, be attentive to the return on the investment.

At this point, let’s focus on what you as a leader must do to improve the performance of individuals anywhere along the continuum. Let’s begin with the marginal performer and then move to the acceptable performer who demonstrates the potential to excel.


Moving the Marginal Performer to Acceptable Performance
To move the marginal performer to an acceptable level of performance, you need to gain comfort and competence in first setting the minimal performance expectations. Then measure acceptable performance to determine how large the gap is between measured performance and the expectation. Finally, coach to close the gap between the employee’s actual performance and the performance expectation.

A coaching model for the marginal performer will be described later. The key with moving the marginal performer is to identify the barriers to performance. Usually, something’s missing. It could be a lack of ability, willingness, resources, energy, or direction.

The toughest barrier to address is lack of willingness: it’s hard to help an employee improve when they don’t want to do so. Sometimes the only intervention to address this barrier is to terminate employment or sever the contract. Of course, this is the last resort, not the first resort.

Moving the Acceptable Performer to Excellence
Moving a worker toward excellence is challenging. But the rewards are greater for the organization – and for you as a leader who will be held accountable for leveraging the talents of others. In contrast to the marginal performer, the first step with the acceptable performer is to acknowledge their current contributions and express that you know that they have more potential to offer to the urgent care center.

Be prepared for workers to ask, “What’s in it for me if I move toward excellence?” For workers who are intrinsically motivated, the ultimate answer could be that they will experience pride in their work, knowing that they have done their best for the benefit of others. But even for such altruistic workers, the answer that satisfies them likely will involve receiving special recognition or the promise of some tangible benefit, such as a bonus, salary increase, or more vacation time.

Just as with a marginal performer, you must observe actual performance and how it stacks up against a standard of excellence. There will be a gap between actual performance and the standard of excellence, and it is your job to guide the worker in closing that gap by offering coaching.

While coaching, you have to identify the obstacles that are preventing the acceptable performer from achieving excellence on a consistent basis. Are there obstacles related to ability, willingness, resources, energy, and/or direction?

Another technique to use with these workers is to ask them to share their insights; “Tell me about a time when you were at your best…the peak.” By asking a question like this and by listening attentively, you will be able to discern the key success factors that enable them to perform at the top of their game. Once you identify the key success factors, then you have to remind them of these factors and assist them in bringing to bear on this current performance challenge.


The Essence of Managing Employee Performance: Coaching
Coaching has become a buzz word today in leadership and management. External coaches are held accountable for generating a return on investment,1 and leaders functioning as coaches should be held accountable for the same.
Beyond the hype, coaching is a four-step process in which leaders proactively seek to increase the potential and contribution of any worker along the continuum of performance.

You now know some techniques for managing employee performance toward specific targets. Coaching is part and parcel of both of these strategies. The evidence is mounting that coaching is effective. For instance, in one study, it was found that coaching improves productivity, quality, organizational strength, and even the bottom line.2

Coaching begins and ends with actual, observed performance. The first step is to observe performance as a way of assessing it. How does the employee perform, and what happens as a result? What’s driving the employee’s performance? Hurting it?

The second step: Communicate clearly to the worker what behavior is expected from them. For instance, a customer service expectation may be to answer the phone on the third ring and introduce himself by name and position. A clinical expectation may be to ask the patient to repeat the discharge instructions to ensure understanding and adherence.

The third step is to monitor the employee’s actual performance with a variety of methods. These can include direct observation, data from reports, observations by others, and even 360-degree evaluations. The fourth step is to study the gap between the actual performance and the performance standard. You seek to close that gap by collaboratively developing strategies to enable the individual to meet the expectation. The employee has succeeded when she starts meeting or beating the expectation.

To improve your chances of success in coaching an individual to “close the gap,” you want to focus on their strengths,3 offer routine feedback frequently,4 and catch them doing something right.5 Furthermore, you want to align their performance behavior with the vision, strategies, and goals of the urgent care center.6

The Art of Performance Coaching
Coaching focuses on learning. You want the individual performer to learn in the way defined by Kolb as “the process whereby knowledge is created through the transformation of experience.”7 When you serve as a coach, your employee is not only gaining and applying knowledge, but also engaging in reflective practice; this is the core of what it means to be a professional.

While you are coaching individual performers, you must attend not only to the performance target and their actual performance, but also to their emotions surrounding the performance target, their performance, and the gap. Carver and Scheier note that progress towards targets is based upon not only “closing the gap” from a behavioral point of view, but also on making sure that the individual performer feels positive about “closing the gap.”8

Culture Kills Expectations: A Warning for Urgent Care Leaders

Don’t do as I do, do as I say. This famous cliché points out the ugly reality that there is a big difference between the formal and informal culture of an urgent care center. The formal culture is expressed in the vision, mission, and values of the center. In contrast, the informal culture is articulated by what folks really do on a daily basis that is allowed, rewarded, reinforced, and punished.

My definition of culture is “how we do things around here.”
Many urgent care centers have policies and procedures which may or may not be enforced or embraced. You also have expectations which may or may not be the subject of commitment or compliance. I was reminded of how culture kills expectations when a physician leader told me the story of how two of his physician partners did not arrive on a timely basis to see patients and did not complete charts accurately or on time, in spite of the fact that these behaviors distracted other staff—including other physicians—and also caused problems in care coordination, reimbursement, and access to care (not to mention frustration among those physicians who reported to work on time and completed their charts accurately and on time).

The non-physician staff described this as “the tale of two cities” —one in which physicians get to do what they want because they are privileged and one in which the rest of the staff has to “tow the line.” What’s your advice to this physician leader about how to improve coordination of care, capture revenue, and increase satisfaction among physicians and other staff? By now, you can probably guess my advice to this physician leader. It is quite simple. Either manage to the expectations or change the expectation, but know that if you change the expectation that your strategy may not be executed.

Managing Employee Performance: In A Nutshell
Managing employee performance is one of the key tasks for any effective leader or manager. As the urgent care leaders, you must first be crystal clear about what is required by your staff to achieve your key clinical and business goals. You must translate your urgent care center vision, mission, values, strategies, and goals into easy-to-understand performance expectations.

Let’s briefly return to the opening vignette. This vision of a high-performing urgent care center ideally begins with you as the leader and is then communicated with inspiration to the staff. For those of you that are a bit cynical or pessimistic, the opening vignette may have seemed a bit far fetched. I would argue that your patients and your staff deserve nothing less. Why in the world would you envision an urgent care center that is anything other than high performing? Why would you seek to lead and manage an urgent care center that is anything less than high performing?

You must monitor the performance of all staffers and then offer them feedback on how to close the gap between expected and actual performance. Finally, you must apply consequences, both positive and negative, after you have coached your staff to achieving a higher level of performance, whether they begin as a marginal or an acceptable performer.

An investment of time and coaching in each and every member of your team is an investment in the value of each member of the team and in the patients that you serve in your urgent care center. Unlike many other managerial responsibilities, you cannot delegate or outsource the performance management of your team. You are where the buck stops. Employee performance begins with you.


References
1. Cross, J. (2000). A fresh look at return on investment. Redwood City, CA: Smartforce.
2. Sloan, K. & Utts, D. (2003). Coaching on purpose: Lessons from the field on implementing a results-focused executive coaching initiative. OD Practitioner, 35(2), 34-38.
3. Buckingham, M. & Coffman, C. First, break all the Rules. New York: Simon & Schuster, 1999.
4. Brooks, D. & Brooks, L. Seven secrets of successful women: New York: McGraw Hill, 1999.
5. Blanchard, K. Heart of a leader. Tulsa: Honor Books, 1999.
6. Cunning, S.M. February 2004. Avoid common management pitfalls. Nursing Management, p.18.
7. Kolb, D.A. (1984). Experiential learning: Experience as the source of learning and development. Engelwood Cliffs, NJ: Prentice Hall.
8. Carver, C.S. & Scheier, M.F. (1998). On the self-regulation of behaviour. Cambridge, UK: Cambridge University Press.

Managing Employee Performance: A Path to Clinical and Business Excellence
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