How can good performance among doctors be maintained?

The Royal College of Physicians, the BMA, the Patients' Association, and the Institute of Health Care Management (among others) have backed the Department of Health's call for doctors to have annual appraisals, for continuing professional development, and for the revalidation of doctors.¹ The collective concern of these bodies is to ensure that doctors continue to develop their competence and provide a high standard of care for patients. What evidence is there that these strategies make a difference?

Feedback on performance and objective setting are the two fundamental components of appraisal. The evidence is strong that feedback on individuals' job performance is associated with improvements in performance and reductions in error rates across all employment sectors.² Moreover, setting goals is associated with improved performance, particularly where the goals are set collaboratively with professionals and where they are specific and challenging (rather than vague or “do your best” goals).² Training (or continuing professional development) has been shown to improve job performance, quality, and organisational performance and service across employment sectors, and to reduce costs.³ In health care, one study of 600 consultations before and after training of general practitioners found that improved consultation skills and medical knowledge were associated with the quality of medical performance, as judged by adherence to protocols.⁴

Evidence of the effectiveness of these practices in the health sector is limited. However, in a study of the link between such people management practices and hospital performance, the findings showed strong negative associations between these practices and patient mortality.⁵ Controlling for a variety of possible third factors (including number of doctors per 100 beds and prior levels of patient mortality) showed that the extent and sophistication of appraisal in hospitals predicted substantial mortality of patients over a three year period. The greater the extent and the more sophisticated the level of appraisals across all staff groups, the lower the patient mortality. Links were also found with the sophistication of training for staff and the proportion of staff working in teams.

So it is not just whether, but how, appraisal, training, continuing professional development, and revalidation are employed that will determine whether they have a positive impact on doctors' performance (and thereby patient care). Research evidence shows that the most potent element of appraisal is goal setting.⁶ Doctors who are clear about their objectives and priorities are more likely to perform well. These objectives should be aligned with the objectives of the organisation of which they are a part (NHS or primary care trusts) since the organisation is likely to have the information that enables identification of local health needs and priorities in patient care. The objectives agreed during the appraisal should be limited in number (five to seven) and should include annual objectives focused on improving specific aspects of clinical performance (informed partly by the results of clinical audit), quality of interaction with patients (a fundamental component of good care) and performance as a team member. Teamwork, in a wide variety of healthcare settings, has been shown to predict quality of and innovation in patient care.⁷ The skills of teamworking can be taught and developed and should be appraised regularly, with feedback being sought from fellow team members on doctors' performance.⁸

The value of appraisals also depends on whether the appraiser is skilled in conducting appraisals and is supportive, focused on the future, and participative. Badly conducted appraisals depress rather than improve performance.⁶ Moreover, the data provided to inform the appraisal should come from a number of appropriate and independent sources.⁶ These should include the results of clinical audit, feedback from peers, patients, and from fellow team members. As Pringle et al (p 704) make clear, the data must also relate appropriately to the objectives of good practice. Unwisely chosen data can deflect rather than focus good practice. In most organisations, appraisals also focus on general contributions to the good functioning of the organisation (called “organisational citizenship”).⁹

Turning to training, research indicates that it will be most effective if doctors' training is related to patient care and to the existing and emerging health needs of their communities. Training and continuing professional development should be driven not by what is available, nor simply by the doctor's own areas of interest, but also by patients' healthcare needs. Moreover, unless opportunities exist to apply the training in their work it is unlikely to contribute to doctors' performance. Doctors must therefore weigh the value of particular activities in training or continuing professional development in terms of how well they help address priorities in patient care, their NHS or primary care trust's objectives, and their opportunities to apply the training in their practice.

As to revalidation, little direct evidence exists of its effectiveness. Indirectly, much research evidence indicates that reviewing one's work objectives, strategies for meeting them, skills, training needs, and working relationships leads to improved performance.¹⁰ If revalidation enables doctors to reflect on their work objectives, their effectiveness, and their skill needs in providing the best patient care, and then to make appropriate changes, it will benefit patient care.

In summary, the Department of Health's proposals for ensuring doctors' sustained good performance are wise, but their implementation should be experienced as encouraging and enabling. Moreover, those who conduct appraisals, identify training needs, and provide continuing professional development and training must be sufficiently skilled to ensure that these activities benefit patient care rather than simply meet administrative requirements.

See also p 704