Appraisals in Healthcare: Are Traditional Performance Appraisals Suitable for Healthcare Workers?

Further work is required in healthcare settings to create productive systems for ongoing reviews that accumulate in an annual review that focuses on the individual’s growth or continuing professional development.

Appraisals can be summarised as “a formal documented system for the periodic review of an individual’s performance” (Moon 1993, pg. 8). Healthcare workers have been subjected to annual appraisals for many years (compulsory in the United Kingdom National Health Service [NHS ] since 2002), with regulators using the completion figures to assess the quality of an organisation. It could be strongly argued that this promotes quantity rather than quality, which questions the ability to assess the value of an individual’s appraisal.

Appraisals are still a topic that causes most despondency amongst a workforce (Fletcher and Williams 2016). In the United Kingdom National Health Service staff survey for 2016, 87% of staff reported that they received an appraisal, with quality scored at an average of 3.1 out of 5 (NHS England 2017). Despite scrutiny at a national level, paradoxically every organisation has the liberty to develop a unique system for staff appraisals. The CIPD (2016) reported that processes have remained broadly static for the last 20 years. The scale used to assess quality from the NHS staff survey demonstrates the lack of a ‘quality’ appraisal for healthcare workers, although the assessment of quality is personal for the individual and may have some correlation to the organisation’s process.

Although each organisation has the liberty to develop their own appraisal process there are some commonalties: usually a review of the previous year—what went well, w hat didn't go so well and t hen setting objectives for the next year. Objectives can be related to the overall corporate objectives, aligning to the strategy of the organisation or they can be more about individual achievements, including contribution to the team. Is this an appropriate model? Should issues only be addressed annually? What measurement is being used to assess the individual? How do you engage with the process when it’s not relevant to a particular post? Many questions are apparent from appraisal systems with the structure, delivery, process and relevance. In fact, in accordance with Moon’s (1993) summary of an appraisal, what constitutes a reasonable period of time? It could be suggested that annually is not good enough.

What Stops Managers from Having Worthwhile Appraisals?

Ultimately appraisals are a mandate of the organisation where alignment or synergy between strategy, operations and the ability of the workforce might dictate future prospects. Sometimes subjective views by an organisation with regards to performance can affect schemes such as ‘ pay per performance’, and t his undermines the priority of the individual and personal development objectives. However, tangible performance metrics can get in the way of an appraisal as they are too focused on the organisation, rather than the individual. Does this result in a disengaged appraisee?

From an organisational point of view performance appraisals may be a miraculous panacea for many issues; however, this stands in stark contrast with the perception of employees, even high performing ones, that performance appraisals are frustrating, bureaucratic, highly demotivating and often unrelated to their job profile (Culbertson et al. 2013). The annual assessment and development plan can, to an extent, be treated as conflicting in the wider performance management function. How can an appraiser act as both judge and coach? How can an appraisee trust the appraiser enough to disclose areas of deficit knowing that it might affect job grade and promotional prospects?

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The changing landscape of organisational structures, which now consists of non-traditional permutations such as temporary work, semiautonomous teams and freelancing, further complicated by mergers, acquisitions and third-party service provisions, warrants an overhaul of the traditional appraisal process. Managers have to manoeuvre amidst such ‘murky waters’ with the added disadvantage of bearing restrictive constraints such as financial deficits, time-bound targets and resource shortages; all the while fostering a friendly environment. These other pressures can diminish the concept and importance of appraisals, which in turn are perceived negatively by the appraisee. Furthermore, the skills, views and the personality of the appraiser may be the cause of significant bias in an appraisal process and hinder a productive meeting for the appraisee. How can this be stopped though?

Considering the erratic and evolving nature o f healthcare, change is always imminent. Therefore organisational objectives are prone to change, which in turn would affect the individual's objectives. The achievement of strategies and operational objectives relies heavily on the support of an effective workforce; further representing the need for a comprehensive system which is more responsive. From a healthcare organisational point of view, positive employee engagement is a priority; research suggests a correlation between happy staff and happy patients (Pinder et al. 2013).

The Future of Appraisals?

Weightman (1996) identified that healthcare systems appraisals are interconnected—from job description, to objectives, to coaching, regular reviews and annual reviews that incorporate reward processes. However, this does not address the concern of individuals, despite the suggestion being ideal. The matter of quality for individuals is pertinent to their engagement with the process and to ensure the improvement of an organisation. Therefore with the introduction of timely information digitally, should individual performance metrics be incorporated into regular and annual reviews? Is there an opportunity to have accurate detail on individual infection control compliance, patient satisfaction, skills used, outcomes of patients they were treating or caring for, and compliance or competence of their role? This would measure impact rather than activity, allowing clear information that’s based on facts. This may be very useful for those members of staff who are at the top of their profession or grade, where progression and rewards are not necessarily available or an incentive. This model would present clear objectives that can be measured, rather than being a subjective account, which is likely completed by someone you seldom meet.

Conclusion

To improve appraisals, it is vital that the appraiser is the reporting manager of the appraisee and there is a simple system in place for dedicated time regularly throughout the review year. Setting these periodic reviews will ensure the recorded annual appraisal is competently informed. The appraiser should be appropriately trained to lead and manage people, as well as skilled in reviewing objectives and developing individuals. Contained in the Healthcare Leadership Model (NHS Leadership Academy 2013) a domain identifies that leaders should be ‘developing capability’ of their team. It implies there should be an ongoing process where trust can be built within a coaching environment, this will in turn improve the quality of appraisals for an individual. If issues of underperformance are recognised, this can then be addressed continually, rather than at an annual event. Staff are likely to be more perceptive to feedback throughout the year and have opportunities to improve before the annual appraisal. This could open the annual appraisal simply to agree previous meetings and actions, allowing emphasis at this meeting for ongoing development of individuals, ensuring that there is a focus on the future, rather than the past.

 
Key Points

• Improvements in quality are required for healthcare workers’ appraisals
  
• Annual appraisals are unsuitable for the changing environment of healthcare
  
• Leaders and managers are required to know their staff in order to complete a comprehensive appraisal
  
• Regular meetings would ensure a focus on the future, rather than the past