1. Performance Appraisal on Dr. Zamfirova, Internal Medicine
Developed and Written by:
Mandy Maloney, Alison Tubay, Madlen Zamfirova, Ashley Borja
2. Background Research:
There are many varying factors that can determine the quality of performance.
Unfortunately, these factors are not standardized and may not be consistent between different
settings. This holds true for internal medicine physicians as well. Research has shown a variety
of tools and methods that are used for these performance appraisals. We first gathered
background knowledge from different databases and journals, then we consulted with SMEs in
the field to see if our research was consistent with what is commonly used in Dr. Z’s practice.
The first article we found discussed the aspect of visit length and if that should be used as
an indicator for quality in primary care (Druss & Mechanic, 2003). From their review, the
researchers were able to conclude that a doctor who spends more time during a consultation is
more likely to include more aspects of care, therefore making appointment length an indicator
for quality (Druss & Mechanic, 2003). With constant advancements in medicine and technology,
physicians are able to do so much more for their patients during visits which has caused an
increase in appointment time. It is up to the physician to take advantage of these new
opportunities, which is why the statement could be made that a physician of higher quality would
spend more time with their patients. There are different circumstances that come into play that
could affect the length of a session, regardless of the quality of the physician. Patients who are
more ill, new to the practice, or unsure of a diagnosis will typically need more time during than
visit than those who are healthy and only visiting for a follow-up appointment (Druss &
Mechanic, 2003). The doctors themselves play a large factor in the visit length as well; some
doctors who work in organized practices are efficient and take less time than doctors who work
alone (Druss & Mechanic, 2003). Overall, this article acknowledges points both for and against
the use of visit length as an indicator of quality in physicians. Quality of care could be one way
to measure the performance of physicians, but at the end of the day, it is important to focus on
how well the time was spent rather than how much time was spent.
An article by Weng, Hess, Lynn, Holmboe & Lipner (2010) discussed if there is a valid
way to differentiate between high and low performing physicians. For years, physicians’
cognitive skills have been evaluated through professional certification examinations, which test
their knowledge of clinical processes and outcomes of care (Weng et al., 2010). Unfortunately,
these exams do not cover the full spectrum of a physician’s clinical competence, so they need
other measures to determine one’s level of clinical performance. A clinical performance
assessment is considered the quantitative assessment of physicians’ performance based on the
rates that their patients experience certain outcomes of care and/or the rates at which physicians
stick to evidence based processes in their practice (Weng et al., 2010). There are challenges
when it comes to measuring the level of performance, especially when it comes to documenting
and reporting the information (some offices do not use electronic recording). The reliability and
validity of these reports can be affected by a number of factors, including but not limited to the
number of patients per physician, the availability of evidence-based quality measures, baseline
rates for each measure, and the extent of practice system differences (Weng et al., 2010).
Because there are so many factors that can affect the individual measures, researchers needed a
more accurate way to represent the level of performance. Instead of using individual measures
for each category, composite measures should be used to better represent a physician’s overall
care and obtain a higher level of accuracy for the measures. If reliable, these composite scores
3. can be used as a “standard,” or a score to base high and low levels of performance off of. This
study used information from 957 internal medicine physicians to develop a clinical performance
assessment that overcomes the various barriers that are encountered in individual physician
performance measurement. They used the data collected to develop composite measure scores
that allowed researchers to reliably and accurately measure a physician’s level of performance
(Weng et al., 2010). These scores were weighted according to the importance and relevance of
the measure, which was determined through the use of a Likert scale. It is necessary that
researchers have a fair way to assess physician performance, and composite scores are a feasible
way to achieve this.
In an article by Hays, Folly, Cladon, McCrorie, McAvoy, McManus & Rethans (2002),
the topic of capacity to change is discussed. Capacity to change means that an individual has
insight into their personal strengths and weaknesses, these insights are valid and consistent with
actual measures, and that there is motivation to improve (Hays et al., 2002). In undergraduate
and graduate school, students are challenged to address their strengths and weaknesses through
various assignments and projects; this awareness of the areas they thrive and lack in allows them
to find ways to improve and strengthen their weaknesses. In the professional world, this
emphasis is sometimes lost. Many practices will encourage their employees to go to different
trainings and further their education due to the constantly changing field of medicine, but it is
really up to the individual to really reflect on themselves. Most times, a doctor may not know
they are performing poorly until some sort of malpractice has occurred (Hays et al., 2002). By
having self-awareness, awareness of others, and being able to reflect and make judgements,
physicians will be more equip to better themselves and their practice. Measuring the capacity to
change helps doctors remain current (Hays et al., 2002). Doctors can remain current through
continuing education and different programs, but with the addition of feedback at the conclusion
of the program, they can address their real needs in their practice. Measuring the capacity to
change can also help screen doctors with reported problems to determine their capacity for
remediation (Hays et al., 2002). Researchers can use an assessment that measures the doctors
own self-assessment compared to an external assessment. This will allow the doctor to see how
well they are actually doing compared to how well they think they do. It is important that
doctors maintain insight and a capacity to change throughout their career; the field is always
changing with new information and technology, and it is essential that doctors stay current to
maintain quality performance.
Historically, there has been a plethora of ways for calculating physician productivity and
compensation. The most common method has been to develop volume-based metrics associated
with the number of patients seen or the amount of revenue collected (or billed for). Today,
physician productivity and compensation are based on RVUs. Relative Value Unites (RVUs) are
a representation of the time, skill, training, and intensity required of a physician to provide a
given service (Merritt Hawkins, 2011). For example, a well patient visit would be assigned a
lower RVU than an invasive surgical procedure; meaning, a physician seeing two or three
complex patients per day could accumulate more RVUs than a physician seeing ten or more low
acuity patients (Merritt Hawkins, 2011). This method measures and rewards the behavior of
“work” rather than number of patients or billings. While other methods of measuring
productivity and quality exist, the use of RVUs has been highly significant and is expanding.
4. Although RVUs are widely used today, many physicians and employers are not entirely
sure how to structure this RVU-based compensation (Merritt Hawkins, 2011). This article
provides ten recommendations to consider when implementing RVU-based appraisal tools. They
are as follows: 1) keep in simple, 2) ensure administrators and physicians have a clear
understanding, 3) stay informed of developments with the RVU methods, 4) don’t believe the
myth, 5) consider hospital and physician alignment, 6) include quality incentives, 7) be practical,
8) consider having a tiered plan, 9) be aware of political risk, and 10) remember there is a
shortage of physicians.
- Keep it simple: Using an RVU-based compensation system allows physicians to
focus on patient care instead of spending time on managing the business.
- Ensure administrators and physicians have a clear understanding: All must
understand the basis of the formula being used and how it will be instrumental in
determining compensation and work value.
- Stay informed of developments with the RVU methods: All procedure codes used
in billing have a corresponding Relative Value. These are periodically updated so it is
important to have the most current information.
- Don’t believe the myth: No system is perfect; meaning, the RVU model will never
be able to treat every physician equally – it is up to the organization to ensure that
there are other methods for measuring performance.
- Consider hospital and physician alignment: RVU-based systems can act as a
bridge from fee-for-service to value based models by allowing doctors to treat
patients without concern for their insurance status.
- Include quality incentives: Satisfaction and outcome metrics should also be used
when calculating RVUs to ensure that other aspects of physicians’ daily jobs are
accounted for; move towards evidence-based methods.
- Be practical: The compensation structure should pay the doctor fairly and be
economically sustainable for the employer over time; turnover must be factored in as
- Consider having a tiered plan: As the practice becomes more profitable, the
physician earns a greater percentage of that margin.
- Be aware of political risks: The medical associated owns the copyrights of all CPT
codes and associated RVUs. Budget neutrality must be maintained when
implementing an RVU system – there is little room for individual organizational
- Remember there is a shortage of physicians: Salaries must be at a fair market
value. There is an increasing demand of physicians and in order to attain employees
and prevent turnover, physicians must be compensated fairly.
Since relative Value Units, or RVUs, are the most commonly-used system for measuring
physician productivity, there are many sources detailing the system. Although most
organizations possess automatic systems for calculating RVUs, the basic theory behind the
system is as follows: it is a ratio combining work for a given service, relative practice cost, and
relative practice cost for professional liability insurance (Seime & Manley, 1999). This article
provides background information on the usage of RVUs; additionally, the authors explain how
and why this system can be used for years to come. Coincidentally, this method is still in use
5. today and although it has flaws, it provides organizations with a (generally) accurate tool of
assessing physicians’ work. The general calculation is presented below:
TOTAL RVU = work RVU + practice expense + malpractice expense.
- Note: “work RVU” is represented by the time and intensity of work involved.
Using the intricate system for calculating RVUs, organizations can determine appropriate
payment. For example, a Neurologist responsible for operating on patients’ brains and spinal
cords (a highly-sensitive and time-consuming task) will collect more payment based on RVU
compared to an Internist responsible for general, primary care. By comparing the type of practice
with the time spent with patients as well as the revenue produced, organizations can develop a
way of scaling physicians’ productivity. This system allows for level-based compensation; more
importantly, it allows for the creating of expectation standards for any given position or practice.
By comparing one internist to another (given that they are in similar professional circumstances),
organizations can appraise performances in a relatively equal manner.
The “best” way for assessing physician productivity and performance is not clear; more
importantly, this is not a simple task. Strategies for assessing physician productivity are often
used only as evaluation tools, but they can also be used along with productivity-based
compensation programs to reward and stimulate productivity (Akl et. al., 2012). Akl and
colleagues (2012) conducted a systematic review of several existing studies addressing the
productivity of physicians. The authors aimed to prove that assessing productivity within the
workplace has positive consequences for both the faculty as well as the employing organization.
Although the statistical evidence was lacking, this article provides great insight into the
challenges faced by assessors. Overall, the authors conclude that productivity should
undoubtedly be a factor when calculating compensation and growth; however, there are several
challenges to keep in mind (listed below):
- Measuring productivity is not a clear-cut task; use multiple methods.
- Faculty may have little to no control over their productivity; make sure to account for
- The lack of timely and accurate billing data may hinder the appearance of
productivity; issues with insurance, for example.
- In many cases, productivity data is self-reported; be aware of potential falsification.
- Faculty may have concerns about the fairness, accuracy, and timeliness of the
- The assessment of clinical productivity does not account for teamwork – may affect it
negatively by promoting competition.
Finally, many physicians dedicate a portion of their time to teaching. This component of
the job may be a requirement from the organization, or, it can be a personal decision made by the
doctor. In any case, when a doctor is responsible for teaching medical students or residents, it is
important to be able to measure those efforts. An article by Yeh and Cahill details the various
aspects that should be accounted for with regards to physicians on faculty. Because teaching
productivity is not easily quantified, it may be undervalued and poorly compensated (Yeh &
Cahill, 1999). The authors of this article, who are both practicing Internal Medicine Physicians,
6. aimed to create a way of measuring physician teaching productivity in order to ensure fair
compensation as well as to promote changes where necessary. According to Yeh and Cahill
(1999) medical teaching possesses four components, which are: (1) time required for the
teaching task, (2) educational value, (3) labor intensity, and (4) degree of patient risk and
responsibility assumed. Based on these four components, it was suggested that relative value
units (RVUs) be used to assess the success of teaching; this method, first introduced in the
1990s, is still used today. Simply put, RVUs are ratios describing the worth of a unit of time
spent teaching relative to the same unit of time spent in clinical practice (Yeh & Cahill, 1999).
RVUs are calculated to measure clinical practice productivity as well as teaching productivity –
because teaching and clinical activities both produce income, an RVU-based system assessing
them on the same scale would ensure clinician-educators are rewarded appropriately (Yeh &
The results of this study found that faculty internists (physicians who are involved in both
clinical and teaching activities) produced 10% more RVU through their educational efforts
compared to clinical practice alone (Yeh & Cahill, 1999). This means that although 10% is not a
huge increase, teaching does increase organizational productivity. Therefore, there is great value
in measuring physician teaching efforts. By quantifying teaching, organizations can determine
whether or not it is effective, where changes should be implemented, and how to fairly
compensate the faculty.
The Medical Director, a coworker, and a subordinate will complete the performance
appraisal for each physician. The coworker and subordinate will be selected at random. It is
important to have ratings from both coworkers and subordinates to give insight to certain
behaviors and task performances that the Medical Director is not always present to observe
themself. Patients will also have the chance to rate their physician through a Patient Satisfaction
Survey (see Appendix 2 for more information).
Rater error training and frame of reference training will be provided prior to the
administration of the performance appraisal. Rater error training will provide examples of
common errors that are made in an effort to prevent them. Many raters tend to be too lenient or
severe with their ratings, so it is important that the raters are aware of how to properly rate each
person correctly. Frame of reference training will then implemented for all raters. This training
will be beneficial for the raters because it will put them in the mindset of a real situation, give
them an opportunity to assess and rate the situation, and then receive feedback from a group on
how well their rating matched up with other individuals.
The performance appraisal will be conducted on a 5 point Likert scale. The scale ranges
from 1 (unsatisfactory) to 5 (excellent). An “unable to assess” option was included in the event
that an appraiser has no insight into a physician’s performance in a specific area or task; this
option will be not be scored. This will allow the appraiser a choice that will not affect the
7. physician’s overall score by being forced to choose a different response. Specific to the
performance of an Internal Medicine Physician, the following behavioral anchors can be used to
represent each score:
1: The Physician being evaluated needs improvement/further development in this area.
3: The Physician being evaluated meets the satisfactory expectation in this area.
5: The Physician being evaluated exceeds the expectations in this area and goes above
and beyond to do so.
At the completion of the scoring, each physician should have 3 different scores, each
representing a different major work behavior. These individual scores are calculated by adding
up the values designated for each of the responses chosen and dividing that value by the number
of items in that section. The following table explains the distribution between low, moderate, and
high construct scores:
1 point Low Score
3 points Moderate Score
5 points High Score
The Physician will receive an overall composite score as well. This overarching number will be
helpful for the Medical Director when trying to get a general idea of how well the Physician is
performing in all aspects of medical care. This number will reflect the performance appraisal
responses. To calculate the composite score, you will add up all values designated for each of
the responses chosen. The following table explains the distribution between low, moderate, and
high overall scores:
< 20 points Low Score
21-45 points Moderate Score
46-70 points High Score
Patient Satisfaction Survey scores (see Appendix 2) and RVUs (see Appendix 1) will be used as
supplemental information to the individual and composite scores. Values for these two scores
will vary depending on the amount of visits the physician has completed and the number of
patients the physician has seen. These scores will be factored in accordingly.
Akl, E. A., Meerpohl, J. J., Raad, D., Piaggio, G., Mattioni, M., Paggi, M., Gurtner, A.,
Mattarocci, S., Tahir, R., Muti, P., Schunemann, H. J.. 2012. Effects of assessing the
productivity of faculty in academic medical centres: A systematic review. Canadian
Medical Association Journal, 184(11), 602-612.
Druss, B., & Mechanic, D. (2003). Should visit length be used as a quality indicator in primary
care? The Lancet, 361(9364), 1148. doi:10.1016/S0140-6736(03)12968-6
Hays, R. B., Jolly, B. C., Caldon, L. M., McCrorie, P., McAvoy, P. A., McManus, I. C., &
Rethans, J. -. (2002). Is insight important? Measuring capacity to change performance.
Medical Education, 36(10), 965-971. doi:10.1046/j.1365-2923.2002.01317.x
Merritt Hawkins, an AMN Healthcare Company. 2011. RVU based physician compensation and
productivity: Ten recommendations for determining physician
compensation/productivity through relative value units. Retrieved from:
Seime, R. J., Manley, C. R. 1999. Relative value units: Using the new “currency” for
measuring clinical productivity in a productivity/incentive plan. Journal of
Clinical Psychology in Medical Settings, 6(2), 183-201.
Weng, W., Hess, B.J., Lynn, L. A., Holmboe, E. S., & Lipner, R. S. (2010). Measuring
physicians’ performance in clinical practice: Reliability, classification accuracy, and
validity. Evaluation & The Health Professions, 33(3), 302-320.
Yeh, M., Cahill, D. F. 1999. Quantifying physician teaching productivity using clinical relative
value units. Journal of General Internal Medicine, 14. 617-621.