Action 1.22

It is recognised that a single ‘model’ performance review process is unlikely to be readily applicable in health service organisations because of the diversity of occupational groups, and the need to build commitment to performance development processes within each health service organisation by involving key players in the design and review of systems.

However, the primary requirements of a performance review system are to:

• Set and clarify expectations for employees
• Monitor employee performance
• Plan and review employee performance
• Develop employee capability
• Recognise employee achievements
• Resolve unsatisfactory employee performance.

‘Performance review’ and ‘performance development’ describe the systematic processes of goal-setting and periodic one-on-one review of workforce performance.

The organisation is responsible for:

• Establishing a culture in which safe, high-quality care can be delivered
• Assisting members of the workforce to develop their competence and performance by supporting them to achieve agreed goals.

Members of the workforce are responsible for:

• Understanding organisational objectives
• Setting professional goals that are consistent with the organisation’s objectives
• Working collaboratively with the organisation to achieve professional and organisational goals.

Performance review processes present an opportunity for managers and clinicians to clarify reciprocal obligations between organisations and the workforce. Through performance review processes, organisations can state how they will meet their responsibility to clinicians, and clinicians can clarify their obligations to the organisation.

For organisations, this may mean describing how they will provide clinicians with support, resources, training, and access to evidence-based tools and data on their performance, and how time will be allocated to support a clinician’s practice. Performance review also provides an opportunity to describe a clinician’s roles and responsibilities for safety and quality in the organisation.

For clinicians, performance review processes support reflective practice and provide opportunities to identify practice improvements. Reflective practice is effective when accurate and timely data are available that describe and benchmark a clinician’s practice outcomes. Organisations should seek to collect and present clinician-specific data that can be used to support practice improvement and encourage clinicians to participate regularly in performance appraisals.

Develop an effective system

The governing body should ensure that effective performance review systems are in place.

Effective performance review systems rely on continuous, constructive interaction between members of the workforce and their managers. The systems are flexible and responsive, and include, but are not limited to, periodic performance review. The performance review system should include systematic monitoring of each clinician’s participation in formal audit, peer review and continuing professional development, following the requirements of their professional organisation and registration body, and identify individual training needs.

Formal performance review processes may not be in place for members of the workforce who are employed indirectly (for example, through contract or locum arrangements). In these cases, performance management may be addressed by:

• Using the processes for credentialing and scope of clinical practice outlined in Actions 1.23 and 1.24
• Reviewing clinical performance data when contracts are due for renewal
• Addressing feedback or issues identified by the medical advisory committee
• Liaising with the locum agency.

Monitor and review the system

Clearly document the requirements of the organisation’s performance development system. This includes identifying a designated person(s) who is responsible for ensuring compliance with the organisation’s performance development policy. Monitor and report on performance to support effective implementation of the performance development system.

Review the performance of the performance development system, including workforce participation, and actions to respond to training and development needs. Consider how to assess the skills of the clinical workforce when competency-based assessment and training are required.

Examples of evidence

Select only examples currently in use:

• Policy documents about the performance review process for the workforce
• Documented performance development system that meets professional development guidelines and credentialing requirements
• Audit results of the proportion of the clinical workforce with completed performance reviews, including actions taken to address identified training and development needs
• Mentoring or peer-review reports
• Feedback from the workforce about their training needs
• Review and evaluation reports of education and training
• Committee and meeting records in which performance review and credentialing of clinicians are discussed.

‘Performance review’ and ‘performance development’ describe the systematic processes of goal-setting and periodic one-on-one review of workforce performance.

The organisation is responsible for:

• Establishing a culture in which safe, high-quality care can be delivered
• Assisting members of the workforce to develop their competence and performance by supporting them to achieve agreed goals.

Members of the workforce are responsible for:

• Understanding organisational objectives
• Setting professional goals that are consistent with the organisation’s objectives
• Working collaboratively with the organisation to achieve professional and organisational goals.

Performance review processes present an opportunity for managers and clinicians to clarify reciprocal obligations between organisations and the workforce. Through performance review processes, organisations can state how they will meet their responsibility to clinicians, and clinicians can clarify their obligations to the organisation.

For organisations, this may mean describing how they will provide clinicians with support, resources, training, and access to evidence-based tools and data on their performance, and how time will be allocated to support a clinician’s practice. Performance review also provides an opportunity to describe a clinician’s roles and responsibilities for safety and quality in the organisation.

For clinicians, performance review processes support reflective practice and provide opportunities to identify practice improvements. Reflective practice is effective when accurate and timely data are available that describe and benchmark a clinician’s practice outcomes. Organisations should seek to collect and present clinician-specific data that can be used to support practice improvement and encourage clinicians to participate regularly in performance appraisals.

Develop an effective system

The governing body should ensure that effective performance development systems are in place.

The performance development system should include systematic monitoring of each clinician’s participation in formal audit, peer review and continuing professional development, following the requirements of their professional organisation and registration body, and identify individual training needs.

Formal performance development systems may not be in place for members of the workforce who are employed indirectly (for example, through contract or locum arrangements). In these cases, performance management may be addressed by:

• Using the processes for credentialing and scope of clinical practice outlined in Actions 1.23 and 1.24
• Reviewing clinical performance data when contracts are due for renewal
• Addressing feedback or issues identified by the medical advisory committee
• Liaising with the locum agency.

Monitor and review the system

Clearly document the requirements of the organisation’s performance development system. This includes identifying a designated person(s) responsible for ensuring compliance with the organisation’s performance development policy. Monitor and report on performance to support effective implementation of the performance development system.

Review the performance of the performance development system, including workforce participation, and actions to address training and development needs. Consider how to assess the skills of the clinical workforce if competency-based assessment and training are required.

Examples of evidence

Select only examples currently in use:

• Policy documents about the performance review process for the workforce
• Documented performance development system that meets professional development guidelines and credentialing requirements
• Audit results of the proportion of the clinical workforce with completed performance reviews, including actions taken to address identified training and development needs
• Mentoring or peer-review reports
• Feedback from the workforce about their training needs
• Review and evaluation reports of education and training
• Committee and meeting records in which performance review and credentialing of clinicians are discussed.

‘Performance management’ and ‘performance development’ describe the systematic processes of goal-setting and periodic one-on-one review of workforce performance.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established performance development system.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt an organisation performance development system and:

• Review participation in the performance development program for all clinicians and other members of the workforce
• Consider whether the performance development system is appropriately designed, resourced, maintained and monitored
• Periodically review the performance development system to ensure that it follows the agreed processes, engages clinicians and achieves the desired outcomes.

Effective performance development systems rely on continuous, constructive interaction between members of the workforce and their managers. The systems are flexible and responsive, and include, but are not limited to, periodic performance review.

Performance review processes present an opportunity for managers and clinicians to clarify reciprocal obligations between organisations and the workforce. Through performance review processes, organisations can state how they will meet their responsibility to clinicians, and clinicians can clarify their obligations to the organisation.

For organisations, this may mean describing how they will provide clinicians with support, resources, training, and access to evidence-based tools and data on their performance, and how time will be allocated to support a clinician’s practice. Performance review also provides an opportunity to describe a clinician’s roles and responsibilities for safety and quality in the organisation.

For clinicians, performance review processes support reflective practice and provide opportunities to identify practice improvements. Reflective practice is effective when accurate and timely data are available that describe and benchmark a clinician’s practice outcomes. Organisations should seek to collect and present clinician-specific data that can be used to support practice improvement and encourage clinicians to participate regularly in performance appraisals.

Formal performance development systems may not be in place for members of the workforce who are employed indirectly (for example, through contract or locum arrangements). In these cases, performance management may be addressed by:

• Using the processes for credentialing and scope of clinical practice outlined in Actions 1.23 and 1.24
• Reviewing clinical performance data when contracts are due for renewal
• Addressing feedback or issues identified by the medical advisory committee
• Liaising with the locum agency.

Clearly document the requirements of the organisation’s performance development system. This includes identifying a designated person(s) who is responsible for ensuring compliance with the organisation’s performance development policy. Monitor and report on performance to support effective implementation of the performance development system.

Examples of evidence

Select only examples currently in use:

• Policy documents about the performance review process for the workforce
• Documented performance development system that meets professional development guidelines and credentialing requirements
• Audit results of the proportion of the clinical workforce with completed performance reviews, including actions taken to address identified training and development needs
• Mentoring or peer-review reports
• Feedback from the workforce about their training needs
• Review and evaluation reports of education and training
• Committee and meeting records in which performance review and credentialing of clinicians are discussed.