Managing the disruptive physician part 2: The performance pyramid model

The late Dr. Howard Kurz created the performance pyramid model of managing physician performance. He developed it while serving as the medical director for a large group practice in Seattle, WA. He applied these fundamental human resources principles to the medical profession, and we at the Greeley Company feel that it is the best way to manage any type of performance issue.

For those who have not been exposed to this model, the following is a brief review and summary:

The pyramid model illustrates that if you build the foundation layers of the medical staff well, you will have to manage poor performance and take corrective action far less often, which is ultimately a service to yourself as a leader and your colleagues. This proactive, preventive approach will decrease conflict and the likelihood that leaders will be forced to manage a performance issue in the future, thus enhancing collegial satisfaction and harmony.

Layer #1: Appoint excellent physicians. The best predictor of future performance is past performance. Whether a physician is new to your organization or a highly respected seasoned professional, setting appropriate criteria for membership and privileges in multiple dimensions of performance and dealing with critical issues at appointment or reappointment is the best way of managing issues proactively.

Layer #2: Set, communicate, and achieve “buy in” to expectations. In addition to defining good performance, the medical staff must convince its members that the expectations that define a good physician are worthy of being measured.

Layer #3: Measure performance against expectations. The medical staff should create performance measures with specific targets so that the medical staff only measures what it says it is going to measure. The questions and answers are clearly defined and articulated prior to the medical staff measuring physician performance. Setting a high and a low target enables the medical staff to reward and recognize excellent performance rather than merely punish those who do not meet basic professional standards.

Layer #4: Provide Feedback. Not so long ago, physicians learned about performance issues when they received a patient complaint, heard from a plaintiff’s attorney, caused an adverse medical event, or at reappointment. This is a retrospective approach that doesn’t drive constructive change. Instead, it merely provides negative reinforcement for a bad outcome that may or may not have to do with performance. A better approach is to communicate to physicians how they are doing in real time so that they can self-modify and self-manage their practice, both relieving leadership of the burden of intervening and allowing physicians the dignity of their independence, autonomy, and self-respect.

Layer #5: Manage Poor Performance. There are a few individuals who either cannot or will not perform to expectations because they probably never bought into the expectations developed in the second layer of the pyramid. This is the most difficult layer to manage because it involves progressive discipline, the act of customizing increasingly significant interventions designed to decrease the “gap” between a physician’s actual and expected performance. This layer is painful because most of us never received training on how to do address these difficult situations, and the individuals we are up against are often far more experienced and skilled at resisting change than we are at instituting it.

Layer #6: Take corrective action. The medical staff should only take corrective action in the face of an egregious event (rape, aggravated assault, etc.) or after a carefully designed and implemented strategy to help a colleague with sub-standard performance to improve has failed over time. This extreme action may also be the only thing that motivates some physicians to change and to eliminate performance or behaviors that may be self-destructive. Leadership, after all, should be about helping each other be the best that we can be.

Although I like to approach the Pyramid model from the base up, next time I will assume that you already have a disruptive physician on staff who needs to be managed and describe how the pyramid can be put to good use.

All the best,

Jon Burroughs, MD, MBA, CMSL
Senior Consultant,
The Greeley Company