Six steps for getting the best from your residents

Residency Program Insider, May 10, 2005

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Dear residency program colleague:

For years I've encouraged medical staff leaders to move toward a collegial performance improvement culture and away from the "bad apple" approach. This progression is aided by the adoption of the pyramid model for helping every physician be the best physician he or she can be. The pyramid model is based on basic human resource management principles applied by every high-performing organization and has been taught for years by the American College of Physician Executives to help manage physician performance. It should also be embraced by residency programs.

The approach is organized as a pyramid under the accurate assumption that the more time physician leaders spend on the foundation layers, the less time they will have to spend on the upper layers, especially the disruptive tasks of managing poor performance and taking corrective action. The below six steps represents a layer of the pyramid-starting at the foundation and moving up.

Step 1: Recruit excellent residents
The best predictor of future behavior is past behavior. Your role as a DIO, or residency program director or coordinator, will be much easier if you do a good job of selecting good residents. This first step lays the foundation for the whole process of optimizing resident performance.

Step 2: Set and communicate clear expectations
Organizations are often disappointed when resident behavior does not meet expectations. However, few organizations effectively communicate clear expectations, making the mistake of assuming that because residents have studied and trained in medicine for a few years, they are automatically aware of performance expectations.

Holding residents accountable for expectations they don't know about sets both you and them up for failure. Once residents are on board, the hospital should clearly and concisely communicate its expectations. Articulate what is means to be a good physician at your hospital. This is both a powerful and underused tool.

Step 3: Measure performance compared to expectations
Once there is consensus on expectations for residents' performance, you must ensure that every resident is aware that their performance will be measured, how it will be measured, and how it will be compared to their peers' performance.

Step 4: Provide periodic feedback
Once the residency program has established clear expectations and determined how it will measure compliance with these expectations, you should establish yet another expectation-that residents will receive and review their performance data on a regular, periodic basis. Remember, performance data should provide residents with both positive and negative feedback. All too often residents only receive feedback when they have done something wrong. While you should provide residents with periodic feedback to let them know when their behavior has not met expectations, periodic feedback also provides an opportunity to appreciate and thank residents for excellent behavior.

Step 5: Manage poor performance
While most residents will self-correct when presented with good data, there is a small subset who will need more active management. Managing poor performance is the most difficult challenge you face.

Step 6: Take corrective action
For those residents who refuse to improve or are unable to improve, you must take corrective action.

Using this "power of the pyramid" approach-establishing a good foundation with step one and moving up the pyramid-will ensure that you have to spend less and less time and energy on corrective action later.

That's all for this week!

All the best,

Richard Sheff, MD
Chair and Executive Director
The Greeley Company

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