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Dear Director,
I took your advice and met with my hospital CEO. Now he has asked me to evaluate my performance and the ED’s performance last year and give goals for this year. We hadn’t set up any formal goals and while I think I do a great job, I suspect he’ll want more than that. What should I be measuring?

Congratulations on taking the first step of meeting with your CEO and beginning the performance discussion. We probably all think we do a great job, but without having actual goals it’s very tough to look back and rate ourselves. Whether you’re looking back or setting goals for the coming year, there are a variety of performance metrics that I think an ED medical director should own.

While some may be out of your direct control, at the end of the day, the following form the pillars of our day-to-day responsibility.

Operational Metrics
Door-to-doc, bed-to-doc, length-of-stay (all patients or discharged patients), and percentage of patients who leave without being seen (LWBS) should be tracked by your ED, and unless you have exceptional metrics, you’re likely working to improve these. While lab and radiology turn around may be issues to deal with, these other metrics really define how well your operation is working overall.

Core Measures
The days of being accountable only for the core measures related to MI and pneumonia (PN) are over. There has been a fair amount of evolution even within the MI and PN measures. Aspirin and MI are now “topped out” and no longer on the hospital compare website. The PN 4-hour rule became the 6-hour rule and is now defunct. Numerous new core measures, including median door-to-doc and length-of-stay metrics (listed above as operational metrics but are now in the core measure spotlight), as well as pain medicine administration for patients with long bone fractures, are now being reported and results are publicly available. This public reporting and the potential inclusion of these new measures in the Value Based Purchasing (VBP) program make these a very high priority for the hospital president.

While we shouldn’t be held accountable for the 30-day readmission rate, we need to accept responsibility for all the other ED-specific core measures. Because we are dependent on many other departments, we also need to use our relationships with other hospital administrators and department directors to insure that they are performing at the hospital’s standards as well. It’s obviously challenging to be held to a 90th percentile LOS metric if radiology turnaround time is performing in the 50th percentile. In this case, getting benchmarking data is all the more critical.

Patient Satisfaction
While some docs still don’t want to accept that patient satisfaction is an important metric, the fact is that it’s important to the hospital president and there are now reimbursement dollars attached to it. While the HCAHPS scores – which determine 30% of a hospital’s VBP score – are determined by surveying inpatients, CEOs are aware that inpatient patient satisfaction scores are significantly impacted by the ED experience of those admitted through the ED. Everyone is trying to get better, and unless you’re showing improvement, you’re not doing your job.

Budget
Many administrators are evaluated strictly on their financial performance. While I typically see nursing directors have performance evaluation scores tied to the budget (which can include staffing hours and billing), I rarely see it among physician directors. Included in the budget category might be volume growth and also LWBS patients. Some groups can break staffing costs down to the RVU. Ultimately, we need to run a lean and efficient business and I suspect that budget and dollars will begin to show up on our evaluations in the future.

Recruitment
Most chairmen spend a good portion of the summer getting new docs on board and oriented and a good part of the fall recruiting for the following summer. I was told years ago that recruitment is the most important thing a medical director does and I would definitely put it in my top three. If you’re successful, you bring on the right people who buy in to the culture, maintain or improve your performance (and thus contract stability), and fill your shifts. Because of the time involved in recruiting and development, this needs to be part of the skill set of a chairman and should be evaluated.

Ambulance Bypass
Some hospitals can go on ambulance bypass when they’re overwhelmed with volume. However, since each ambulance is worth about $5000 to the hospital, no hospital CEO wants to lose out on these patients. There is clearly a balance between patient safety during a chaotic shift and accepting new patients, but like LWBS, attention to operational efficiency and decreasing LOS will likely decrease ambulance bypass.

Hospital Participation
We need to be good citizens of the hospital and this includes attending committee meetings. Whether it’s the medical director or docs in the group, being visible and involved is critical towards good citizenship. Highlight the nursing and resident education you’ve done as well. Participation can be harder to quantify but it’s critical to our job and should be evaluated.

Setting Goals
Now that you know what to evaluate, we need to establish some rules for goal setting. In the best of circumstances, your CEO will allow you to establish your own goals. However, don’t be surprised if they hand you goals since the hospital board of directors is handing the CEO goals. Ideally, you want to set goals that are achievable yet involve some “reach.” If these benchmarks are tied to a bonus structure, find out if the bonus dollars were really intended to be part of the compensation package that makes the job have competitive pay. If you’re below competitive pay and can’t get the bonus, you might want to start looking for another job. I took a job years ago where it was expected that I would fully achieve the bonus to have a competitive salary. Failure to achieve the bonus would have left me grossly underpaid as a chairman. The problem came when a new CEO decided that part of his cost-cutting strategy was to make achieving bonuses at a 50% rate doable but no one would really get more than that. I thought he wanted to fire me when I got 97% of my bonus that year. Bottom line—understand the relationship between achieving your goals and the bonus and whether the bonus is really a bonus. For these reasons, goals sometimes have three distinct levels that may range from 80% of bonus to 120% of bonus. Think of these as improvement in performance with an achievable goal, hitting a reach goal, to finally truly exemplary performance or a stretch goal. Since we recognize that there is a range of performance from low to high, goals are typically customized to fit your situation and current performance. If your LWBS is currently 9%, it would be unrealistic to think that you could drop it to 2% (about national average) or <1% (best practice). Levels of goals may be a reduction to 4.5% (50% decrease but realistic with some efforts) for level 1, 2% for a level 2 bonus and <1% for a level 3 bonus. On the opposite side, I have a good friend whose patient sat was in the 99th percentile. His level 1 goal for the upcoming year was to maintain a 99th percentile rating. There were no reach or stretch options. Never mind how challenging it is to maintain such exemplary performance from year to year but that’s what his hospital CEO laid out for him and no discussion was going to change it. The one area where hospital CEOs may consistently want certain levels of performance will come with the level that will not cost them Medicare dollars—hitting the benchmark performance for VBP core measures. Bench mark is defined as top 10% in comparison to other hospitals for those core measures contained within the VBP program. That will be very difficult as top 10% performance requires perfection (or near perfection) for core measures related to STEMI and PN care.

Annual evaluations are a critical tool for us to assess our performance and to show our bosses that we’re doing a good job. Be honest in a self evaluation and build the evaluation tool around quantifiable measures. Remember that as core measures expand and have more reimbursement money attached to them for the hospital, we may be held to much higher standards than we think are achievable. Unless your department is exemplary across the board, maintaining the status quo will be unacceptable in the future. So no matter how we cut it, we need to show improvement in the categories that are critical to the hospital and ED performance. Shoot for achievable goals that show an improvement and are aligned with the hospital goals and try to negotiate for more rewards when achieving stretch goals.


Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.


TALK BACK: Write in with your administrative questions and Dr. Silverman will address them in this column.
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