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APPRAISING THE PERFORMANCE OF DENTISTS Robert Isman, D.D.S., M.P.H.* Introduction Evaluate a dentist?! Who ever heard of such an idea?! Dentists are professionals. They aren’t pieceworkers on a factory assembly line. They’re dealing with the health care of human beings. Who is competent to judge them? These comments, with expletives deleted, are typical of the responses one hears whenever the subject of performance appraisal as applied to dentists is brought up. A more pertinent question might be, “Who cares?” Who would want or need to worry about appraising members of a profession, the vast majority of whose members are private entrepreneurs, so long as they had been graduated from an acceptable dental school and could demonstrate their competence to practice by passing a state licensing examination? The simple answer is, “The public.” This paper will take the position that, because it helps finance dental education and spends over four billion dollars annually on dental care? the public has a considerable investment in dentistry and has a right to expect a reasonable level of performance. The fact that state boards of dental examiners exist to license dentists and, to a limited degree, to monitor the dental care provided to the public lends at least some credence to this argument. The primary purpose of this paper, however, is not to discuss performance appraisal of dentists engaged in the private practice of dentistry, although some obvious applications to the private sector exist. Rather, it will discuss the application of performance appraisal methods to dentists working in publicly funded programs. Here the rationale should be more obvious. First, all public programs are increasingly being held accountable for their results. With service agencies that are not profit oriented, accountability usually translates into getting the most “bang for the buck,” i.e., delivering services as efficiently and cost effectively as possible. Second, although still one of the more contentious issues in personnel management, it is both logical and desirable to tie a compensation system to an objective system of performance appraisal. A final purpose of this paper will be to discuss the fact that many dentists in public programs function not merely as clinicians, but also as managers of the other personnel customarily found in a dental office. Thus, the performance appraisal system to be proposed must take into account both of these functions. The conclusions and suggestions in this paper are intended for application in the Dental Health Program of the Division of Health Services for Multnomah County, Oregon. Qualitative Aspects of Performance An extensive review of both the dental and business literature reveals that there has been virtually nothing published in regard to the qualitative aspects of performance. The issue of quality, however, as it relates to the provision of dental care has been addressed by several reporters. 1,3-5,73,10~4-16 Interestingly, much of the writing on the quality of dental care has come from individuals in *Director, Multnomah County Dental Health Division, 426 S.W. Stark Street, Portland, Oregon, 97204
Vol. 37, No. 3--Summer, 1977 the public, rather than the private, sector of dentistry. The underlying rationale for public sector involvement has been that as third parties (e.g., dental service organizations, commercial health insurance companies, Blue Cross and Blue Shield organizations, employer-employee welfare funds, public health departments, and public assistance programs) have become increasingly involved in payment for dental care, the determination of what constitutes “good” dental care has become their concern as well as that of the dentist and the patient. The qualitative aspects of performance appraisal are probably more important insofar as dentistry is concerned, because they provide a better opportunity of measuring the results of the interaction between patient and dentist. Unfortunately, there is no generally accepted definition of or standards for quality as the term is used to evaluate dental care. Friedman states: Dentists, by virtue of their highly technical training, tend to define quality of care in terms of the excellence of the adaptation of fillings to teeth, the fit of bridges and dentures, and the esthetic appearance of restorations. Although these criteria are fundamental to good dental treatment, technical perfection is only one phase of quality. Equally important are the adequacy of the diagnosis and the selection of the plan of treatment that is best suited to the needs of the individual patient.s
In his excellent monograph, A Guide for the Evaluation of Dental Care, Friedman proposes guidelines for evaluating most of the clinical aspects of dental care, from examination, diagnosis, and treatment planning to oral surgery and orthodontics. Further, he proposes specific qualitative criteria (good, satisfactory, and unsatisfactory) for determining the adequacy of both the dentist’s clinical treatment and his judgment. Friedman’s criteria are intended to be applied by an indirect evaluator: that is, the patient’s records are evaluated but the patient is not physically present for the evaluation. Recognizing that this might impair the accuracy of the method, Friedman conducted studies comparing both indirect (patient records) and direct (patient present) methods of evaluation. He found that when a three-point scale (good-satisfactory-unsatisfactory) was used, there was agreement of the direct and indirect evaluators only 51 percent of the time. However, when a two-point scale (satisfactory vs. unsatisfactory) was used, there was an overall 82 percent agreement. When nonfunctional disagreements (i.e., a satisfactory rating by a direct examiner is rated unsatisfactory by an indirect examiner) were accounted for, the overall agreement rose to 87 percent. Friedman proposed that the standards he presented could be used to evaluate dental care in private dental offices, group dental practices, and in the administrative offices of third parties. He recommended adoption of the two-point rating scale and indirect evaluation of a random sample of patients as the method of choice. Certainly, the relatively high level of agreement between direct and indirect examiners, when combined with the large number of persons covered by many third-party organizations, would dictate the use of the indirect method from a cost standpoint alone. For such organizations, the cost of selecting a large enough sample to be statistically significant, plus the cost of acquiring and training dentists or other examiners, plus the administrative difficulties of getting patients who have completed treatment to return to a dental
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office for an evaluation could easily make the direct evaluation method prohibitively expensive or extremely difficult to administer. For a group practice or a smaller public program (e.g. a local dental public health program), however, the direct evaluation method may be more useful and practical. It should be remembered that for approximately 13 percent of the patients reviewed by Friedman, a direct examination detected unsatisfactory treatment that an indirect evaluation had declared was satisfactory. Since the purpose of the qualitative evaluation is to detect and correct unsatisfactory performance, this represents a significant amount of such performance that would have gone undetected and uncorrected if only an indirect method were used. The direct evaluation method, then, can provide the smaller dental practice an opportunity to review the performance of all of its dentists on a routine periodic basis with a relatively good likelihood of detecting unsatisfactory performance from a qualitative perspective.
Who Should Do It? If one accepts the notion and utility of a qualitative performance appraisal, the next question that logically arises is, “Who should do it?” The most prevalent idea to emanate from the private dental sector seems to be that it should be done, if at all, from within the ranks of the profession. Thus, “peer review” is a term that private dentists are hearing more and more. However, the concept of peer review in the private dental sector has in general not been extended to any degree to encompass the area of direct performance evaluation. Rather, peer review seems to imply “fee review.” It is a mechanism that is usually characterized by a reaction from a patient or an insurance carrier claiming that a dentist’s fee is too high, or from a dentist to an insurance carrier protesting that the fee received is too low. There is little concern for the patient, and whether or not he is receiving quality treatment, regardless of who pays the fee or how much it is. The use of peer review as a means of judging a dentist’s performance is more prevalent in dental partnerships and group practices where the performance of one member is more likely to reflect on the reputation of the group. In these situations, it is not uncommon to see the partners regularly sit down together to review their patients’ charts. It is not at all unusual for there to be a group consultation about patients whose treatment is particularly complicated. It is still relatively rare, however, for the members of a dental group to directly review each others’ treatment. At least one public dental program has taken a novel approach to performance appraisal. The dental public health program in Philadelphia, Pennsylvania, under the direction of David Soricelli, contracts with the administration of the Temple University School of Dentistry to perform periodic evaluations of the dentists employed b y the city.I6 The technical criteria used are the same as those used to evaluate the services rendered at the dental school. This formal program has resulted in a gradual improvement in the overall quality of Philadelphia’s program, and a belief on the part of the evaluators that the service performed by the city dentists is probably of higher overall technical quality than that being provided, on the average, in the private sector. Soricelli argues convincingly that all public programs could carry on similar programs at relatively low cost.
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One public program with which the writer is associated has proposed a quality evaluation mechanism that would be both direct and indirect and would have both internal and external components. The internal, indirect component would consist of a review of a random sample of patient charts by a team of dentists working for the program, none of whom would review his own patients. The same team would also perform a direct evaluation, while the patient was present, on a smaller sample of patients. Some of the patients would be in the process of undergoing treatment, so that actual technics used by the dentist under evaluation could be observed. Other patients would be returning for recall examinations so results of earlier treatment could be evaluated. The external evaluation would similarly have both direct and indirect components. Considerable discussion took place around the question of who should do the external evaluation. The major alternatives were either to use the Philadelphia method (dental school faculty) or to use dentists in private practice who are widely recognized b y their peers as expert in their particular fields. In some instances, either method would have resulted in the same person’s being selected. The latter method was finally selected, primarily because it was felt that dentists in general practice would have a more practical understanding of the type of treatment possible in a “real world’ setting, rather than the more idealized conditions that frequently prevail in the cloistered educational environment of a dental school. Although this system currently exists only on paper, it is planned to be implemented shortly. It is hoped that the combination of internal, external, indirect, and direct review will afford the program its maximum opportunity to take advantage of generally accepted qualitative standards for performance appraisal. Quantitative Aspects of Performance
If qualitative measures of dental performance are imprecise and difficult to standardize, standards pertaining to quantity are almost unheard of and hence performance appraisal as measured by quantitative methods is equally rare. In a sense, one quantitative indicator is used to a considerable extent as a performance measure of sorts in dental practices with more than one dentist. That indicator is dollars, usually expressed as some proportion of either dollars collected or dollars’ worth of service produced. In a small practice, where each dentist sees approximately the same mix of patients in terms of age, socioeconomic status, and other indicators of treatment needs, and where each dentist practices with the same number and type of auxiliary personnel; then the production or collection methods of measuring productivity may be fairly acceptable indicators. In practice, these two methods are the most common methods used for determining the compensation level of dentists who become associates of those already in an existing practice. For use in larger practices, and for purposes of comparing the quantitative performance of dentists in different practice settings, however, the production method leaves much to be desired. The primary problem is that there are a multitude of variables that could affect production levels and be difficult to control. For example, adults in general require more extensive, time-consuming, and costly treatment than children. Persons of lower socioeconomic status have
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usually had less exposure to dental care and thus require more extensive treatment. Patients from nonfluoridated communities can be expected to need about twice as much dental care as their fluoridated neighbors. Dentists who make maximum use of dental auxiliaries generally have practices that are more efficient; hence, more productive. Even within a small homogeneous practice, if one dentist assumes administrative as well as clinical responsibilities, his “chairtime” available for production will be less and must be taken into account. There have been attempts to view dental practices through quantitative eyes, although not necessarily with performance evaluation in mind. For example, the American Dental Association conducts periodic surveys of dental practice to determine such things as the number of auxiliaries employed and the number of patients seen in a given period of time.2 Such gross indicators, though, are subject to the same limitations as described.
Other Problems Other problems encountered when using dollars as measures of productivity are (1) the changing value of the dollar, (2) qualitative problems resulting from using compensation as an incentive for increased production, (3) technological changes that decrease the time necessary for certain procedures, and (4)the lack of correspondence of market value with the actual value of the effort that goes into producing a given service. The first factor is easily compensated for by applying some index of changes in general purchasing power, such as the Gross National Product Implicit Price Deflator prepared by the U. S. Department of Commerce. There are a number of problems associated with tying compensation systems to production systems based simply on the numbers of services or the dollar value provided, most of which relate to the many uncontrollable variables referred to earlier. Beyond these, though, one might reasonably expect the quality of care to suffer the more production is emphasized. This, in fact, is the basis for one of the most frequently leveled charges at fee-for-service dentists by those in salaried positions-that the profit motive results in a tendency to overproduce, i.e., to provide more dental care than is really necessary. The counter argument from the fee-forservice dentists, of course, is that being salaried generates an incentive to underproduce which could also be detrimental to the patient’s oral health. Probably both of these charges are true in the absence of the use of any kind of qualitative standards, all of which provide considerable justification for the more routine use of such standards, particularly in practices that tie compensation to production. Technological advancements in dentistry and the lack of correlation between the actual and market value of services demonstrate the need for a more reliable index of productivity than dollars. Technological changes may mean that a service becomes considerably easier and less time-consuming for a dentist to provide, yet the fee for the service, and hence the dollar value attributed to it, might well remain unchanged. Likewise, the usual fees charged for dental services do not necessarily reflect only the time and other costs to the dentist in providing them. Rather, they may be based more on some long-standing but ill-founded tradition, or upon “what the market will bear.”
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Relative Value System One method of avoiding this situation is to use a “relative value” rating system of some kind. Such a system looks at all of the usual services a dentist would perform and then assigns a weight to each, based on factors such as time involved, relative skill needed, and degree to which portions (or all) of the procedure can be accomplished by auxiliary personnel. In such a system, production would be measured in terms of the total number of relative value points accumulated over a given period of time. If a procedure was shortened by a technological innovation, then the relative value would be adjusted downward accordingly to compensate for the change. The relative value system is still prone to some rather subjective judgments about the degree of skill necessary and extent to which tasks can be delegated. One way of avoiding even these variables would be to assume that time is the major element that differentiates the values of different services, and thus weight services primarily on the basis of time alone. Such a method could evaluate a number of dental practices in order to establish an average time length for a given procedure. Each such average, then, would represent the weight of that particular procedure, so that the total number of different procedures multiplied by their respective weights would yield a “service minute” total. Such a system would provide considerable flexibility with respect to the training and experience of the individual dentist, since separate service-minute “norms” could be established for dentists with a variety of experience, training, and practice variables. The primary advantage of this type of quantitative performance measure, however, would be its luck of financial incentive to produce a particularly lucrative (though perhaps unnecessary) type of service. Further, such a system would facilitate the comparison of dentists with varying amounts of time spent in actual patient treatment (vs. “down” time from missed appointments or administrative responsibilities), because goals could be established for an average number of service minutes per available treatment minute. A system that records performance against a predetermined service minute goal has apparently been used by dentists in the Indian Health Service,17 although there have been no published reports of how useful a tool it has been for performance appraisal. Nevertheless, the author believes that such a system is probably the least biased quantitative method available and should be further investigated for its utility as the quantitative component of a dentist performance appraisal program. The Dentist as Manager Throughout this paper, the image portrayed of the dentist has been that of a technician, a sort of “glorified mouth mechanic” whose performance will be considered up to par if he fills enough “holes” fast enough with some degree of quality. Unfortunately, too many members of the public, often including the dentist’s own staff, also view him this way. For it is a regrettable fact that dentists still receive minimal, if any, education in anything other than the technical aspects of dentistry. Courses in patient management are beginning to get a foothold in dental school curricula, but preparation in the effective manage-
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ment of a dental office team, while increasingly recognized as necessary, is still relatively rare. That this situation should still prevail is certainly to the detriment of dentistry. The dentist’s patient is a person, not a tooth. Dentists will surely say that the vast majority of their practice problems have to do with patient management, not with technical proficiency. Managers will just as surely respond that the bulk of their problems are over personnel matters. If dental practice management is so closely linked with patient management and employee management, then perhaps it makes some sense to take a look at the dentist’s performance as a manager. It was stated earlier that the primary focus of this paper would be on publicly funded dental programs as opposed to private dental practice. Such programs, when they involve clinical components at all, usually involve relatively small ones, since dental care in general represents a rather low priority for the public dollar. Thus, it is not unusual to see a number of clinics employ one or two or three dentists, a proportionate number of dental assistants, a receptionist, and perhaps a dental hygienist. In a one-dentist clinic, the dentist is usually the supervisor of at least two auxiliary personnel. In a larger clinic, he may also supervise other dentists. In either situation, though, he is responsible for managing a team in order to provide the most effective and efficient care possible. Clearly, the supervising dentist must possess certain managerical skills in order to carry out his responsibilities well. The appraisal of managerical skills is as important to the overall evaluation of a dentist’s performance as the qualitative and quantitative measurement of his technical abilities. How can one measure the performance of a dentist as a manager? This question has little to do with dentistry but much to do with management, and is one that has perplexed executives and personnel administrators in business, industry, and the public sector for many years. The traditional approach has been based on weighing traits of individuals and individual characteristics of their work, such as ability to get along with people, leadership, analytical ability, industry, judgment, and initiative. Each trait usually carries a range of ratings from unacceptable to outstanding. A number of authors6J1,’8 have pointed out the inadequacies of trait-oriented appraisal systems, and it is not within the scope of this paper to report all those findings. A number of attempts have been made to strengthen the trait approach, such as providing detailed explanations of traits, adding work-oriented qualities, eliciting key result areas as standards, and attempting to improve the rating process. Even as the trait approach has been improved in technic, approach, and content, however, it still has questionable practical validity.12 As the philosophy of management by objectives (MBO)13 has gained in popularity over the past two decades, the practice of appraising managers against verifiable, measurable objectives has also increased. Today it is probably relatively rare to find a business that has not implemented at least some MBO technics. Public agencies, too, have been attracted to MBO tenets as a means of helping to improve public accountability. Most of what this paper has proposed so far, in fact, represents the application of MBO principles, i.e., the establishment of verifiable and measurable qualitative and quantitative standards for dental care. As encouraging as appraisal of managerial perform-
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ance against verifiable objectives is, however, it still leaves much to be desired. The most skilled technician may be unable to manage an enterprise, just as an individual expert in managerial skills may not be a good performer. Koontz,12 in Appraising Managers As Managers, proposes an appraisal program that combines evaluation of performance against verifiable objectives and evaluation of performance as a manager. Performance as a manager is defined in terms of a rating on an extensive list of questions in five major managerial areas: 1. PEanning: Forecasting, establishing written objectives, programs to accomplish objectives, budgeting, scheduling, allocation of time, involvement of subordinates. 2. Organizing: Staffing, job assignments, clarity of staff's responsibilities and authorities, delegation, working relations. 3. Leading: Managing through objectives, initiating action, decision making, communications skill, leadership style, encouragement of expression, resolving conflict situations, gaining cooperation. 4. Motivating: Encouragement of self-development, appraisal and coaching; utilization of skills and abilities of subordinates, attitudes and morale of group, reaction to changes. 5. Controlling: Ways used to measure results; scope of measures; use of objectives, targets, budgets, and policies to measure results; corrective action taken. Koontz has developed a checklist of 73 questions that cover all of the traditional managerial areas of concern listed above. Not all of them apply to all managers, and there are several that would not be applicable to dentist-managers. Those that are relevant and useful are listed in Appendix A. Koontz also developed ratings to be used on each checklist item, as follows: 5.0 Superior: A standard of performance which could not be improved upon under any circumstances or conditions known to the rater. 4.0 or 4.5 Excellent: A standard of performance which leaves little of any consequence to be desired. 3.0 or 3.5 Good: A standard of performance above the average and meeting all normal requirements of the position. 2.0 or 2.5 Average: A standard of performance regarded as average for the position involved and the people available. 1.0 or 1.5 Fair: A standard of performance below the normal requirements of the position but one that may be regarded as marginally or temporarily acceptable. 0.0 Inadequate: A standard of performance regarded as unacceptable for the position involved. It is recognized that there is still a great deal of subjectivity associated with the checklist, and particularly with trying to decide on a rating. Nevertheless, Koontz contends that the large number of relatively specific checkpoints tends to reduce the subjectivity of the overall program. An ideal program would have no subjectivity and the questions would be answerable with a yes or no. Unfortunately, no one seems to have progressed any further on a way to eliminate completely judgment on how well an individual performs.
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This paper has attempted to provide an overview on the subject of performance appraisal of dentists, particularly those in supervisory positions in publicly funded clinical programs. Some of the problems inherent in the definition and measurement of the quality, quantity, and effective management of dental care have been discussed. The qualitative aspects of dental care have been the most thoroughly investigated of the subareas, but primarily with regard to evaluating the care rather than the performance of the person providing it. Less has been written on the quantitative or managerial aspects of appraising a dentist’s performance. While further research is certainly indicated about the appropriateness of the measures proposed and their usefulness in identifying and helping to correct performance deficiencies, the intent is to begin using such a system on a pilot basis rather than waiting for the “perfect” program to come along. As long as the scarcity of public resources for dental care persists, public programs ought to use those appropriate means available to demonstrate their accountability in order to ensure optimal use of public dollars. References 1. Abramowitz, Joseph, and Mecklenberg, R. E. Quality of care in dental practice; the approach of the Indian Health Service. J. Pub. Health Dent., 32:90-99, 1972. 2. American Dental Association, Bureau of Economic Research and Statistics. The 1973 Survey of Dental Practice, Chicago, Ill., The Association 1974. 3. Anon., The Quality of Dental Care in Community Programs, J. Pub. Health Dent., 27:70-82, 1967. 4. Bailit, Howard, et al., Quality of Dental Care: Development of Standards, Am. Dent. A. J., 89~842-853,1974. 5. Cons, N. C., Method for Posttreatment Evaluation of the Quality of Dental Care, J. Pub. Health Dent., 31:104-108, 1971. 6. Dale, E. and Smith, A,, Now Report Cards for Bosses, New York Times Magazine, March 31, 1957. 7. DeJong, N., et al., Methods for Evaluating the Quality of Programs of Dental Care, J. Pub. Health Dent., 30:223-228, 1970. 8. Friedman, J. W., A Guide for the Evaluation of Dental Care, University of California, Los Angeles, 1972. 9. Greene, J. C., The Oral Health Needs of the Nation, The Harvard Dental Alumni Bulletin, 31, Apr. 1971. 10. Jago, J. D., Issues in Assurance of Quality of Dental Care, Am. Dent. A. J., 89:854-865, 1974. 11. Kelly, P. R., Reappraisal of Appraisals, Harvard Business Review, 36,3:60, May-June, 1968. 12. Koontz, H., Appraising Managers as Managers, McCraw Hill Book Co., New York, 1971. 13. Odiorne, G. S. Management by Objectives, Pitman Publishing Corporation, New York, 1965. 14. Schoen, M. H., ed, The Evaluation of the Quality of Dental Care Programs; Summary of Workshop; Asilomar, California; March 1971, U. S. Department of Health Education and Welfare, Hartford, Connecticut, Feb. 1972. 15. Schonfeld, €1. K., Quality of Dental Care, Its Measurement, Description and Evaluation, J. Am. Coll. Dentists, 38:194-206, 1971. 16. Soricelli, D. A,, Methods of Administrative Control for the Promotion of Quality in Dental Programs, Am. J. Pub. Health, 58:1723-1737, 1968. 17. U . S. Department of Health, Education and Welfare, Public Health Service, Health Services Administration, Indian Health Service, Dental Services Branch, Dental Program Efficiency Criteria and Standards for the Indian Health Service, 1974. 18. Whisler, T. L. and Harper, S. F. (eds.), Performance Appraisal: Research and Practice, Holt, Rinehart and Winston, Inc., New York, 1962.
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APPENDIX A PERFORMANCE AS A MANAGER CHECKLIST (Selected from Kontz12) Planning 1. Does he set for his departmental unit both short-term and long-term goals in verifiable terms (either qualitative or quantitative) that are related in a positive way to those of his superior and his company? 2. To what extent does he make sure that the goals of his departnlent are understood b y those who report to him? 3. How well does he assist those who report to him in establishing verifiable and consistent goals for their operations? 4. To what extent does he utilize consistent and approved planning premises in his planning and see that his subordinates do likewise? 5. Does he understand the role of company policies in his decision making and assure that his subordinates do likewise? 6. Does he attempt to solve problems of subordinates by policy guidance, coaching, and encouragement of innovation, rather than by rules and procedures? 7 . To what extent does he seek out applicable alternatives before making a decision? 8. In choosing from among alternatives, does he recognize and give primary attention to those factors which are limiting, or critical, to the solution of a problem? 9. Does he check his plans periodically to see if they are still consistent with current expectations? 10. To what extent does he consider the need for, as well as the cost of, flexibility in arriving at a planning decision? 11. In developing and implementing his plans, does he regularly consider longer-range implications of his decisions along with the shorter-range results expected? 12. When he submits problems to his superior, or when a superior seeks help from him in solving problems, does he submit considered analyses of alternatives (with advantages and disadvantages) and recommend suggestions for solution? Organizing 1. Does the organization structure under his control reflect major result areas? 2. Does he delegate authority to his subordinates in accordance with results expected of them? 3. Does he make his delegations clear (rather than detailed)? 4. Does he formalize in writing his Subordinates’ position guides, authority delegations, and goals? 5. Does he clarify responsibilities for contributions to his programs? 6. Does he maintain adequate control when delegating authority? 7 . Does he exact commensurate responsibility when he delegates authority? 8. When he has delegated authority to his subordinate, does he refrain from making decisions in that area? 9. Does he utilize staff advice when necessary and then only as advice? 10. Does he make sure that committee or group meetings are preceded by proper agenda, information gathering, analyses, and concrete proposals? Staffing 1. Does he take full responsibility for the staffing of his department, even though he obtains needed assistance from the personnel department? 2. Does he take steps to make certain that his subordinates are given opportunity for training for better positions, both in his operations and elsewhere in the company? 3. Does he utilize appropriate methods of training and developing his subordinates?
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4. Does he effectively practice coaching of subordinates as a means of training? 5 . Does he tend to keep subordinates who have questionable ability in their jobs? 6. Does he appraise his subordinates objectively and regularly on the basis of performance against preselected goals? 7. Does he appraise his subordinates objectively and regularly on their ability to manage effectively? 8. Does he use appraisals as a means of helping his subordinates to improve their perf orniance? 9. Does he select, or recommend promotion of his subordinates, on the basis of his objective appraisal of their performance and in the light of the potential for growth in the company? 10. Does he take such steps and make such recommendations as he can to provide adequate and motivating compensation and conditions of work for his subordinates? Directing 1 Does he understand what motivates his subordinates and attempt to build into their position and position environment a situation to which these motivations will respond? 2. Does he so lead and guide his subordinates and interpret company and departmental objectives as to make them see that their own self-interest is in harmony with, although not necessarily the same as, the company’s or department’s goals? 3. Does he issue instructions that are clear, within his authority, and fully understandable to his subordinates? 4. Does he use effective and efficient communications techniques in dealing with subordinates? 5. Does he engage in an appropriate amount of face-to-face contact? 6. Does he create an environment where people are encouraged to suggest innovation in product, process, marketing, or other company planning and policy areas? 7. Is he receptive to innovative ideas, suggestions, and the desire to be heard, whether from his superiors, his equals, or his subordinates? 8. Does he expect his subordinates to suggest changes or express objections to what they may regard as the wrong objectives, policies, and programs, or does he expect blind compliance with company policies and programs and his own decisions? 9. Can his subordinates reach him readily to discuss their problems and obtain guidance? 10. Does he help his subordinates to become oriented to the company’s programs, objectives, and environment? 11. Does he exercise participative leadership when useful and authoritative direction when necessary? 12. Is he effective as a leader (”the capacity and will to rally men and women to a common purpose”)? Controlling 1. How effectively does he tailor his control techniques and standards to reflect his plans? 2. Does he use control techniques, where possible, to anticipate deviations from plans? 3. Do his control techniques and information promptly report deviations from plans? 4. Does he develop and rely upon objective or verifiable control information? 5 . Are his control techniques and information understandable to those who must take action? 6. Does he take prompt action when unplanned variations in performance occur? 7. Does he keep his superior informed of significant (to his superior) problems and errors in his operation, their causes, and steps being taken to correct them?
Journal of Public Health Dentistry
APPRAISING THE PERFORMANCE OF DENTISTS Robert Isman, D.D.S., M.P.H.* Introduction Evaluate a dentist?! Who ever heard of such an idea?! Dentists are professionals. They aren’t pieceworkers on a factory assembly line. They’re dealing with the health care of human beings. Who is competent to judge them? These comments, with expletives deleted, are typical of the responses one hears whenever the subject of performance appraisal as applied to dentists is brought up. A more pertinent question might be, “Who cares?” Who would want or need to worry about appraising members of a profession, the vast majority of whose members are private entrepreneurs, so long as they had been graduated from an acceptable dental school and could demonstrate their competence to practice by passing a state licensing examination? The simple answer is, “The public.” This paper will take the position that, because it helps finance dental education and spends over four billion dollars annually on dental care? the public has a considerable investment in dentistry and has a right to expect a reasonable level of performance. The fact that state boards of dental examiners exist to license dentists and, to a limited degree, to monitor the dental care provided to the public lends at least some credence to this argument. The primary purpose of this paper, however, is not to discuss performance appraisal of dentists engaged in the private practice of dentistry, although some obvious applications to the private sector exist. Rather, it will discuss the application of performance appraisal methods to dentists working in publicly funded programs. Here the rationale should be more obvious. First, all public programs are increasingly being held accountable for their results. With service agencies that are not profit oriented, accountability usually translates into getting the most “bang for the buck,” i.e., delivering services as efficiently and cost effectively as possible. Second, although still one of the more contentious issues in personnel management, it is both logical and desirable to tie a compensation system to an objective system of performance appraisal. A final purpose of this paper will be to discuss the fact that many dentists in public programs function not merely as clinicians, but also as managers of the other personnel customarily found in a dental office. Thus, the performance appraisal system to be proposed must take into account both of these functions. The conclusions and suggestions in this paper are intended for application in the Dental Health Program of the Division of Health Services for Multnomah County, Oregon. Qualitative Aspects of Performance An extensive review of both the dental and business literature reveals that there has been virtually nothing published in regard to the qualitative aspects of performance. The issue of quality, however, as it relates to the provision of dental care has been addressed by several reporters. 1,3-5,73,10~4-16 Interestingly, much of the writing on the quality of dental care has come from individuals in *Director, Multnomah County Dental Health Division, 426 S.W. Stark Street, Portland, Oregon, 97204
Vol. 37, No. 3--Summer, 1977 the public, rather than the private, sector of dentistry. The underlying rationale for public sector involvement has been that as third parties (e.g., dental service organizations, commercial health insurance companies, Blue Cross and Blue Shield organizations, employer-employee welfare funds, public health departments, and public assistance programs) have become increasingly involved in payment for dental care, the determination of what constitutes “good” dental care has become their concern as well as that of the dentist and the patient. The qualitative aspects of performance appraisal are probably more important insofar as dentistry is concerned, because they provide a better opportunity of measuring the results of the interaction between patient and dentist. Unfortunately, there is no generally accepted definition of or standards for quality as the term is used to evaluate dental care. Friedman states: Dentists, by virtue of their highly technical training, tend to define quality of care in terms of the excellence of the adaptation of fillings to teeth, the fit of bridges and dentures, and the esthetic appearance of restorations. Although these criteria are fundamental to good dental treatment, technical perfection is only one phase of quality. Equally important are the adequacy of the diagnosis and the selection of the plan of treatment that is best suited to the needs of the individual patient.s
In his excellent monograph, A Guide for the Evaluation of Dental Care, Friedman proposes guidelines for evaluating most of the clinical aspects of dental care, from examination, diagnosis, and treatment planning to oral surgery and orthodontics. Further, he proposes specific qualitative criteria (good, satisfactory, and unsatisfactory) for determining the adequacy of both the dentist’s clinical treatment and his judgment. Friedman’s criteria are intended to be applied by an indirect evaluator: that is, the patient’s records are evaluated but the patient is not physically present for the evaluation. Recognizing that this might impair the accuracy of the method, Friedman conducted studies comparing both indirect (patient records) and direct (patient present) methods of evaluation. He found that when a three-point scale (good-satisfactory-unsatisfactory) was used, there was agreement of the direct and indirect evaluators only 51 percent of the time. However, when a two-point scale (satisfactory vs. unsatisfactory) was used, there was an overall 82 percent agreement. When nonfunctional disagreements (i.e., a satisfactory rating by a direct examiner is rated unsatisfactory by an indirect examiner) were accounted for, the overall agreement rose to 87 percent. Friedman proposed that the standards he presented could be used to evaluate dental care in private dental offices, group dental practices, and in the administrative offices of third parties. He recommended adoption of the two-point rating scale and indirect evaluation of a random sample of patients as the method of choice. Certainly, the relatively high level of agreement between direct and indirect examiners, when combined with the large number of persons covered by many third-party organizations, would dictate the use of the indirect method from a cost standpoint alone. For such organizations, the cost of selecting a large enough sample to be statistically significant, plus the cost of acquiring and training dentists or other examiners, plus the administrative difficulties of getting patients who have completed treatment to return to a dental
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office for an evaluation could easily make the direct evaluation method prohibitively expensive or extremely difficult to administer. For a group practice or a smaller public program (e.g. a local dental public health program), however, the direct evaluation method may be more useful and practical. It should be remembered that for approximately 13 percent of the patients reviewed by Friedman, a direct examination detected unsatisfactory treatment that an indirect evaluation had declared was satisfactory. Since the purpose of the qualitative evaluation is to detect and correct unsatisfactory performance, this represents a significant amount of such performance that would have gone undetected and uncorrected if only an indirect method were used. The direct evaluation method, then, can provide the smaller dental practice an opportunity to review the performance of all of its dentists on a routine periodic basis with a relatively good likelihood of detecting unsatisfactory performance from a qualitative perspective.
Who Should Do It? If one accepts the notion and utility of a qualitative performance appraisal, the next question that logically arises is, “Who should do it?” The most prevalent idea to emanate from the private dental sector seems to be that it should be done, if at all, from within the ranks of the profession. Thus, “peer review” is a term that private dentists are hearing more and more. However, the concept of peer review in the private dental sector has in general not been extended to any degree to encompass the area of direct performance evaluation. Rather, peer review seems to imply “fee review.” It is a mechanism that is usually characterized by a reaction from a patient or an insurance carrier claiming that a dentist’s fee is too high, or from a dentist to an insurance carrier protesting that the fee received is too low. There is little concern for the patient, and whether or not he is receiving quality treatment, regardless of who pays the fee or how much it is. The use of peer review as a means of judging a dentist’s performance is more prevalent in dental partnerships and group practices where the performance of one member is more likely to reflect on the reputation of the group. In these situations, it is not uncommon to see the partners regularly sit down together to review their patients’ charts. It is not at all unusual for there to be a group consultation about patients whose treatment is particularly complicated. It is still relatively rare, however, for the members of a dental group to directly review each others’ treatment. At least one public dental program has taken a novel approach to performance appraisal. The dental public health program in Philadelphia, Pennsylvania, under the direction of David Soricelli, contracts with the administration of the Temple University School of Dentistry to perform periodic evaluations of the dentists employed b y the city.I6 The technical criteria used are the same as those used to evaluate the services rendered at the dental school. This formal program has resulted in a gradual improvement in the overall quality of Philadelphia’s program, and a belief on the part of the evaluators that the service performed by the city dentists is probably of higher overall technical quality than that being provided, on the average, in the private sector. Soricelli argues convincingly that all public programs could carry on similar programs at relatively low cost.
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One public program with which the writer is associated has proposed a quality evaluation mechanism that would be both direct and indirect and would have both internal and external components. The internal, indirect component would consist of a review of a random sample of patient charts by a team of dentists working for the program, none of whom would review his own patients. The same team would also perform a direct evaluation, while the patient was present, on a smaller sample of patients. Some of the patients would be in the process of undergoing treatment, so that actual technics used by the dentist under evaluation could be observed. Other patients would be returning for recall examinations so results of earlier treatment could be evaluated. The external evaluation would similarly have both direct and indirect components. Considerable discussion took place around the question of who should do the external evaluation. The major alternatives were either to use the Philadelphia method (dental school faculty) or to use dentists in private practice who are widely recognized b y their peers as expert in their particular fields. In some instances, either method would have resulted in the same person’s being selected. The latter method was finally selected, primarily because it was felt that dentists in general practice would have a more practical understanding of the type of treatment possible in a “real world’ setting, rather than the more idealized conditions that frequently prevail in the cloistered educational environment of a dental school. Although this system currently exists only on paper, it is planned to be implemented shortly. It is hoped that the combination of internal, external, indirect, and direct review will afford the program its maximum opportunity to take advantage of generally accepted qualitative standards for performance appraisal. Quantitative Aspects of Performance
If qualitative measures of dental performance are imprecise and difficult to standardize, standards pertaining to quantity are almost unheard of and hence performance appraisal as measured by quantitative methods is equally rare. In a sense, one quantitative indicator is used to a considerable extent as a performance measure of sorts in dental practices with more than one dentist. That indicator is dollars, usually expressed as some proportion of either dollars collected or dollars’ worth of service produced. In a small practice, where each dentist sees approximately the same mix of patients in terms of age, socioeconomic status, and other indicators of treatment needs, and where each dentist practices with the same number and type of auxiliary personnel; then the production or collection methods of measuring productivity may be fairly acceptable indicators. In practice, these two methods are the most common methods used for determining the compensation level of dentists who become associates of those already in an existing practice. For use in larger practices, and for purposes of comparing the quantitative performance of dentists in different practice settings, however, the production method leaves much to be desired. The primary problem is that there are a multitude of variables that could affect production levels and be difficult to control. For example, adults in general require more extensive, time-consuming, and costly treatment than children. Persons of lower socioeconomic status have
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usually had less exposure to dental care and thus require more extensive treatment. Patients from nonfluoridated communities can be expected to need about twice as much dental care as their fluoridated neighbors. Dentists who make maximum use of dental auxiliaries generally have practices that are more efficient; hence, more productive. Even within a small homogeneous practice, if one dentist assumes administrative as well as clinical responsibilities, his “chairtime” available for production will be less and must be taken into account. There have been attempts to view dental practices through quantitative eyes, although not necessarily with performance evaluation in mind. For example, the American Dental Association conducts periodic surveys of dental practice to determine such things as the number of auxiliaries employed and the number of patients seen in a given period of time.2 Such gross indicators, though, are subject to the same limitations as described.
Other Problems Other problems encountered when using dollars as measures of productivity are (1) the changing value of the dollar, (2) qualitative problems resulting from using compensation as an incentive for increased production, (3) technological changes that decrease the time necessary for certain procedures, and (4)the lack of correspondence of market value with the actual value of the effort that goes into producing a given service. The first factor is easily compensated for by applying some index of changes in general purchasing power, such as the Gross National Product Implicit Price Deflator prepared by the U. S. Department of Commerce. There are a number of problems associated with tying compensation systems to production systems based simply on the numbers of services or the dollar value provided, most of which relate to the many uncontrollable variables referred to earlier. Beyond these, though, one might reasonably expect the quality of care to suffer the more production is emphasized. This, in fact, is the basis for one of the most frequently leveled charges at fee-for-service dentists by those in salaried positions-that the profit motive results in a tendency to overproduce, i.e., to provide more dental care than is really necessary. The counter argument from the fee-forservice dentists, of course, is that being salaried generates an incentive to underproduce which could also be detrimental to the patient’s oral health. Probably both of these charges are true in the absence of the use of any kind of qualitative standards, all of which provide considerable justification for the more routine use of such standards, particularly in practices that tie compensation to production. Technological advancements in dentistry and the lack of correlation between the actual and market value of services demonstrate the need for a more reliable index of productivity than dollars. Technological changes may mean that a service becomes considerably easier and less time-consuming for a dentist to provide, yet the fee for the service, and hence the dollar value attributed to it, might well remain unchanged. Likewise, the usual fees charged for dental services do not necessarily reflect only the time and other costs to the dentist in providing them. Rather, they may be based more on some long-standing but ill-founded tradition, or upon “what the market will bear.”
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Relative Value System One method of avoiding this situation is to use a “relative value” rating system of some kind. Such a system looks at all of the usual services a dentist would perform and then assigns a weight to each, based on factors such as time involved, relative skill needed, and degree to which portions (or all) of the procedure can be accomplished by auxiliary personnel. In such a system, production would be measured in terms of the total number of relative value points accumulated over a given period of time. If a procedure was shortened by a technological innovation, then the relative value would be adjusted downward accordingly to compensate for the change. The relative value system is still prone to some rather subjective judgments about the degree of skill necessary and extent to which tasks can be delegated. One way of avoiding even these variables would be to assume that time is the major element that differentiates the values of different services, and thus weight services primarily on the basis of time alone. Such a method could evaluate a number of dental practices in order to establish an average time length for a given procedure. Each such average, then, would represent the weight of that particular procedure, so that the total number of different procedures multiplied by their respective weights would yield a “service minute” total. Such a system would provide considerable flexibility with respect to the training and experience of the individual dentist, since separate service-minute “norms” could be established for dentists with a variety of experience, training, and practice variables. The primary advantage of this type of quantitative performance measure, however, would be its luck of financial incentive to produce a particularly lucrative (though perhaps unnecessary) type of service. Further, such a system would facilitate the comparison of dentists with varying amounts of time spent in actual patient treatment (vs. “down” time from missed appointments or administrative responsibilities), because goals could be established for an average number of service minutes per available treatment minute. A system that records performance against a predetermined service minute goal has apparently been used by dentists in the Indian Health Service,17 although there have been no published reports of how useful a tool it has been for performance appraisal. Nevertheless, the author believes that such a system is probably the least biased quantitative method available and should be further investigated for its utility as the quantitative component of a dentist performance appraisal program. The Dentist as Manager Throughout this paper, the image portrayed of the dentist has been that of a technician, a sort of “glorified mouth mechanic” whose performance will be considered up to par if he fills enough “holes” fast enough with some degree of quality. Unfortunately, too many members of the public, often including the dentist’s own staff, also view him this way. For it is a regrettable fact that dentists still receive minimal, if any, education in anything other than the technical aspects of dentistry. Courses in patient management are beginning to get a foothold in dental school curricula, but preparation in the effective manage-
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ment of a dental office team, while increasingly recognized as necessary, is still relatively rare. That this situation should still prevail is certainly to the detriment of dentistry. The dentist’s patient is a person, not a tooth. Dentists will surely say that the vast majority of their practice problems have to do with patient management, not with technical proficiency. Managers will just as surely respond that the bulk of their problems are over personnel matters. If dental practice management is so closely linked with patient management and employee management, then perhaps it makes some sense to take a look at the dentist’s performance as a manager. It was stated earlier that the primary focus of this paper would be on publicly funded dental programs as opposed to private dental practice. Such programs, when they involve clinical components at all, usually involve relatively small ones, since dental care in general represents a rather low priority for the public dollar. Thus, it is not unusual to see a number of clinics employ one or two or three dentists, a proportionate number of dental assistants, a receptionist, and perhaps a dental hygienist. In a one-dentist clinic, the dentist is usually the supervisor of at least two auxiliary personnel. In a larger clinic, he may also supervise other dentists. In either situation, though, he is responsible for managing a team in order to provide the most effective and efficient care possible. Clearly, the supervising dentist must possess certain managerical skills in order to carry out his responsibilities well. The appraisal of managerical skills is as important to the overall evaluation of a dentist’s performance as the qualitative and quantitative measurement of his technical abilities. How can one measure the performance of a dentist as a manager? This question has little to do with dentistry but much to do with management, and is one that has perplexed executives and personnel administrators in business, industry, and the public sector for many years. The traditional approach has been based on weighing traits of individuals and individual characteristics of their work, such as ability to get along with people, leadership, analytical ability, industry, judgment, and initiative. Each trait usually carries a range of ratings from unacceptable to outstanding. A number of authors6J1,’8 have pointed out the inadequacies of trait-oriented appraisal systems, and it is not within the scope of this paper to report all those findings. A number of attempts have been made to strengthen the trait approach, such as providing detailed explanations of traits, adding work-oriented qualities, eliciting key result areas as standards, and attempting to improve the rating process. Even as the trait approach has been improved in technic, approach, and content, however, it still has questionable practical validity.12 As the philosophy of management by objectives (MBO)13 has gained in popularity over the past two decades, the practice of appraising managers against verifiable, measurable objectives has also increased. Today it is probably relatively rare to find a business that has not implemented at least some MBO technics. Public agencies, too, have been attracted to MBO tenets as a means of helping to improve public accountability. Most of what this paper has proposed so far, in fact, represents the application of MBO principles, i.e., the establishment of verifiable and measurable qualitative and quantitative standards for dental care. As encouraging as appraisal of managerial perform-
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ance against verifiable objectives is, however, it still leaves much to be desired. The most skilled technician may be unable to manage an enterprise, just as an individual expert in managerial skills may not be a good performer. Koontz,12 in Appraising Managers As Managers, proposes an appraisal program that combines evaluation of performance against verifiable objectives and evaluation of performance as a manager. Performance as a manager is defined in terms of a rating on an extensive list of questions in five major managerial areas: 1. PEanning: Forecasting, establishing written objectives, programs to accomplish objectives, budgeting, scheduling, allocation of time, involvement of subordinates. 2. Organizing: Staffing, job assignments, clarity of staff's responsibilities and authorities, delegation, working relations. 3. Leading: Managing through objectives, initiating action, decision making, communications skill, leadership style, encouragement of expression, resolving conflict situations, gaining cooperation. 4. Motivating: Encouragement of self-development, appraisal and coaching; utilization of skills and abilities of subordinates, attitudes and morale of group, reaction to changes. 5. Controlling: Ways used to measure results; scope of measures; use of objectives, targets, budgets, and policies to measure results; corrective action taken. Koontz has developed a checklist of 73 questions that cover all of the traditional managerial areas of concern listed above. Not all of them apply to all managers, and there are several that would not be applicable to dentist-managers. Those that are relevant and useful are listed in Appendix A. Koontz also developed ratings to be used on each checklist item, as follows: 5.0 Superior: A standard of performance which could not be improved upon under any circumstances or conditions known to the rater. 4.0 or 4.5 Excellent: A standard of performance which leaves little of any consequence to be desired. 3.0 or 3.5 Good: A standard of performance above the average and meeting all normal requirements of the position. 2.0 or 2.5 Average: A standard of performance regarded as average for the position involved and the people available. 1.0 or 1.5 Fair: A standard of performance below the normal requirements of the position but one that may be regarded as marginally or temporarily acceptable. 0.0 Inadequate: A standard of performance regarded as unacceptable for the position involved. It is recognized that there is still a great deal of subjectivity associated with the checklist, and particularly with trying to decide on a rating. Nevertheless, Koontz contends that the large number of relatively specific checkpoints tends to reduce the subjectivity of the overall program. An ideal program would have no subjectivity and the questions would be answerable with a yes or no. Unfortunately, no one seems to have progressed any further on a way to eliminate completely judgment on how well an individual performs.
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This paper has attempted to provide an overview on the subject of performance appraisal of dentists, particularly those in supervisory positions in publicly funded clinical programs. Some of the problems inherent in the definition and measurement of the quality, quantity, and effective management of dental care have been discussed. The qualitative aspects of dental care have been the most thoroughly investigated of the subareas, but primarily with regard to evaluating the care rather than the performance of the person providing it. Less has been written on the quantitative or managerial aspects of appraising a dentist’s performance. While further research is certainly indicated about the appropriateness of the measures proposed and their usefulness in identifying and helping to correct performance deficiencies, the intent is to begin using such a system on a pilot basis rather than waiting for the “perfect” program to come along. As long as the scarcity of public resources for dental care persists, public programs ought to use those appropriate means available to demonstrate their accountability in order to ensure optimal use of public dollars. References 1. Abramowitz, Joseph, and Mecklenberg, R. E. Quality of care in dental practice; the approach of the Indian Health Service. J. Pub. Health Dent., 32:90-99, 1972. 2. American Dental Association, Bureau of Economic Research and Statistics. The 1973 Survey of Dental Practice, Chicago, Ill., The Association 1974. 3. Anon., The Quality of Dental Care in Community Programs, J. Pub. Health Dent., 27:70-82, 1967. 4. Bailit, Howard, et al., Quality of Dental Care: Development of Standards, Am. Dent. A. J., 89~842-853,1974. 5. Cons, N. C., Method for Posttreatment Evaluation of the Quality of Dental Care, J. Pub. Health Dent., 31:104-108, 1971. 6. Dale, E. and Smith, A,, Now Report Cards for Bosses, New York Times Magazine, March 31, 1957. 7. DeJong, N., et al., Methods for Evaluating the Quality of Programs of Dental Care, J. Pub. Health Dent., 30:223-228, 1970. 8. Friedman, J. W., A Guide for the Evaluation of Dental Care, University of California, Los Angeles, 1972. 9. Greene, J. C., The Oral Health Needs of the Nation, The Harvard Dental Alumni Bulletin, 31, Apr. 1971. 10. Jago, J. D., Issues in Assurance of Quality of Dental Care, Am. Dent. A. J., 89:854-865, 1974. 11. Kelly, P. R., Reappraisal of Appraisals, Harvard Business Review, 36,3:60, May-June, 1968. 12. Koontz, H., Appraising Managers as Managers, McCraw Hill Book Co., New York, 1971. 13. Odiorne, G. S. Management by Objectives, Pitman Publishing Corporation, New York, 1965. 14. Schoen, M. H., ed, The Evaluation of the Quality of Dental Care Programs; Summary of Workshop; Asilomar, California; March 1971, U. S. Department of Health Education and Welfare, Hartford, Connecticut, Feb. 1972. 15. Schonfeld, €1. K., Quality of Dental Care, Its Measurement, Description and Evaluation, J. Am. Coll. Dentists, 38:194-206, 1971. 16. Soricelli, D. A,, Methods of Administrative Control for the Promotion of Quality in Dental Programs, Am. J. Pub. Health, 58:1723-1737, 1968. 17. U . S. Department of Health, Education and Welfare, Public Health Service, Health Services Administration, Indian Health Service, Dental Services Branch, Dental Program Efficiency Criteria and Standards for the Indian Health Service, 1974. 18. Whisler, T. L. and Harper, S. F. (eds.), Performance Appraisal: Research and Practice, Holt, Rinehart and Winston, Inc., New York, 1962.
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APPENDIX A PERFORMANCE AS A MANAGER CHECKLIST (Selected from Kontz12) Planning 1. Does he set for his departmental unit both short-term and long-term goals in verifiable terms (either qualitative or quantitative) that are related in a positive way to those of his superior and his company? 2. To what extent does he make sure that the goals of his departnlent are understood b y those who report to him? 3. How well does he assist those who report to him in establishing verifiable and consistent goals for their operations? 4. To what extent does he utilize consistent and approved planning premises in his planning and see that his subordinates do likewise? 5. Does he understand the role of company policies in his decision making and assure that his subordinates do likewise? 6. Does he attempt to solve problems of subordinates by policy guidance, coaching, and encouragement of innovation, rather than by rules and procedures? 7 . To what extent does he seek out applicable alternatives before making a decision? 8. In choosing from among alternatives, does he recognize and give primary attention to those factors which are limiting, or critical, to the solution of a problem? 9. Does he check his plans periodically to see if they are still consistent with current expectations? 10. To what extent does he consider the need for, as well as the cost of, flexibility in arriving at a planning decision? 11. In developing and implementing his plans, does he regularly consider longer-range implications of his decisions along with the shorter-range results expected? 12. When he submits problems to his superior, or when a superior seeks help from him in solving problems, does he submit considered analyses of alternatives (with advantages and disadvantages) and recommend suggestions for solution? Organizing 1. Does the organization structure under his control reflect major result areas? 2. Does he delegate authority to his subordinates in accordance with results expected of them? 3. Does he make his delegations clear (rather than detailed)? 4. Does he formalize in writing his Subordinates’ position guides, authority delegations, and goals? 5. Does he clarify responsibilities for contributions to his programs? 6. Does he maintain adequate control when delegating authority? 7 . Does he exact commensurate responsibility when he delegates authority? 8. When he has delegated authority to his subordinate, does he refrain from making decisions in that area? 9. Does he utilize staff advice when necessary and then only as advice? 10. Does he make sure that committee or group meetings are preceded by proper agenda, information gathering, analyses, and concrete proposals? Staffing 1. Does he take full responsibility for the staffing of his department, even though he obtains needed assistance from the personnel department? 2. Does he take steps to make certain that his subordinates are given opportunity for training for better positions, both in his operations and elsewhere in the company? 3. Does he utilize appropriate methods of training and developing his subordinates?
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4. Does he effectively practice coaching of subordinates as a means of training? 5 . Does he tend to keep subordinates who have questionable ability in their jobs? 6. Does he appraise his subordinates objectively and regularly on the basis of performance against preselected goals? 7. Does he appraise his subordinates objectively and regularly on their ability to manage effectively? 8. Does he use appraisals as a means of helping his subordinates to improve their perf orniance? 9. Does he select, or recommend promotion of his subordinates, on the basis of his objective appraisal of their performance and in the light of the potential for growth in the company? 10. Does he take such steps and make such recommendations as he can to provide adequate and motivating compensation and conditions of work for his subordinates? Directing 1 Does he understand what motivates his subordinates and attempt to build into their position and position environment a situation to which these motivations will respond? 2. Does he so lead and guide his subordinates and interpret company and departmental objectives as to make them see that their own self-interest is in harmony with, although not necessarily the same as, the company’s or department’s goals? 3. Does he issue instructions that are clear, within his authority, and fully understandable to his subordinates? 4. Does he use effective and efficient communications techniques in dealing with subordinates? 5. Does he engage in an appropriate amount of face-to-face contact? 6. Does he create an environment where people are encouraged to suggest innovation in product, process, marketing, or other company planning and policy areas? 7. Is he receptive to innovative ideas, suggestions, and the desire to be heard, whether from his superiors, his equals, or his subordinates? 8. Does he expect his subordinates to suggest changes or express objections to what they may regard as the wrong objectives, policies, and programs, or does he expect blind compliance with company policies and programs and his own decisions? 9. Can his subordinates reach him readily to discuss their problems and obtain guidance? 10. Does he help his subordinates to become oriented to the company’s programs, objectives, and environment? 11. Does he exercise participative leadership when useful and authoritative direction when necessary? 12. Is he effective as a leader (”the capacity and will to rally men and women to a common purpose”)? Controlling 1. How effectively does he tailor his control techniques and standards to reflect his plans? 2. Does he use control techniques, where possible, to anticipate deviations from plans? 3. Do his control techniques and information promptly report deviations from plans? 4. Does he develop and rely upon objective or verifiable control information? 5 . Are his control techniques and information understandable to those who must take action? 6. Does he take prompt action when unplanned variations in performance occur? 7. Does he keep his superior informed of significant (to his superior) problems and errors in his operation, their causes, and steps being taken to correct them?
