CHAPTER 9

Case Study: Carilion Health System

Here is a practical case study that includes performance appraisal, the development of a performance improvement plan, and follow-up coaching to improve employee performance. It contains principles, forms, and techniques that can be adapted to any size or type of organization.

Creating Synergy Between Coaching and Performance Management

Performance management is a continuous process in which the manager engages in two-way communication with employees regarding expectations, performance, areas for development, and plans for enhancing performance. For a performance management system to be successful, it must be supported by and aligned with the company’s organizational goals, culture, leadership style, operating strategy, and job design.

The components of performance management that are discussed in this chapter include:

•Performance appraisal

•The performance plan

•Developmental goals and action steps

•Application—coaching process

•Tools

•Case study

Carilion Health System is the largest employer in western Virginia, with more than 9,400 employees. Carilion’s eight affiliated hospitals, Level 1 Trauma Center, Cancer Center of Western Virginia, Medical Education, and more than 150 physician practices serve our community with modern health care.

In 2004, Carilion embarked on a revision of its performance management with system priorities and initiatives as described in the system scorecard (Appendix A). A specific emphasis was placed on the creation of a common language for competencies and behaviors. In addition, a scorecard metric focusing on strategic alignment and developmental goals was established.

The following is an example of Carilion’s performance management system, including defined components and a case study example.

Carilion’s performance management process includes an annual written review, with established coaching priorities on developmental needs and gaps identified at the annual review and during periodic checks. Managers gather data for the review and performance plan using 360° assessments. (These assessments include reviews by a superior, peer-level, and employee viewers and customers. These are chosen on the basis of frequency of interaction.) Employees receive individualized reviews and performance plans that are agreed upon with the manager. The review consists of an appraisal tool (Appendix B) that evaluates the employee on significant responsibilities and service standards. The manager summarizes the review on the basis of observations and the 360° assessments. The performance plan includes established developmental, operational, and career goals (Appendix C). As the performance plan is implemented, a defined focus is placed on closing the gap between developmental needs, business opportunities, and operational success. To close the gap, an action plan is implemented that includes definitions, timelines and application components (Appendix C). For a successful outcome, coaching occurs between the manager and the employee. Carilion defines coaching as an active process that brings about change in an individual’s thoughts, attitudes, and behaviors related to agreed-upon performance expectations.

Coaching exists as a tool for managers to engage employees in real-world situations while reinforcing expected behaviors and outcomes. Managers use coaching to support change in the work environment. Coaching builds on the manager’s belief that individuals are accountable for their actions and decisions and that they have the resources to solve their own challenges.

The manager-as-coach uncovers talents and resources that were not previously imagined. By showing genuine interest, the manager improves relationships and builds on talent through use of the following:

•Asking questions

•Giving clear direction

•Giving feedback

•Improving performance through a learning and growth environment

•Stimulating creativity and motivation to act

Carilion managers coach employees on a continuous basis utilizing formal and informal opportunities. Carilion’s Corporate University team created a formal definition, model, and process that is utilized (Appendix D). The following case study is an example of a Carilion director coaching her newly acquired manager in a formal manner.

In a manager-as-coach scenario, the need for coaching is established during the performance review process. In this case, the director, Susan, acquired a new manager, Don, through consolidation of departments within Nursing Services.

1. Establish the need. Susan reviews Don’s current performance plan and other available data, completes the 360° assessment process, and develops Don’s annual review. Operationally, Don is not meeting his established targets for length of stay and staff turnover; in addition, he is not scoring at meets-standard on quality measures. Developmentally, 360°s reveal negative attitude, poor communication skills, and lack of knowledge and application to develop his employees.

Susan shares the review and performance plan with Don and discusses the plan for progression, which includes coaching as an action step. The plan is agreed upon. The first phase of Don’s coaching focuses on communication.

The following is Don’s initial performance plan:

PERFORMANCE PLAN

2. Create a relationship. Typically, the manager-as-coach already has an established relationship with the coachee. Since this case involved a new relationship, both relationship and readiness for change developed simultaneously. The first two coaching sessions were spent uncovering expectations and Don’s vision and goals for his unit.

3. Evaluate readiness for change. As the relationship develops, Don’s readiness for change becomes apparent to Susan. At this point, Don decides if he is willing to put forth the effort to make the necessary changes. With this decision, he has the option to leave the role.

4. Determine commitment to coaching. Don is ready and eager to accept coaching because he has the desire to be an exceptional leader. Susan understands the time intensity on her part.

5. Use discovery and observation. The 360° assessment only scratches the surface with regard to Don’s developmental needs. Susan has not directly observed Don’s leadership skills, so it is necessary for her to see his day-to-day activities. Susan’s goal is to spend time observing Don in situations in which she can see the leadership skills that have an impact on his developmental plan.

Susan observes Don in a staff meeting, leading and interacting with his staff. Susan also spends a day on Don’s unit observing his staff and then his communication skills as they impact the team. Susan inquires about Don’s unit’s vision and goals, and whether employees are aware of them. This helps Susan define what the specific communication issues are, ensure that the performance plan is on track, and develop more defined action steps.

6. Establish the plan: specific action strategies. The following are the specific strategies and revised performance plan, based on new data:

PERFORMANCE PLAN

7. Implement the coaching plan. Once the specific action steps are identified and timelines are established, Susan and Don agree on points to check progress. Susan and Don meet every other week and share examples of data Don is implementing. In implementation, Susan utilizes questions and challenges to open space for Don to continue to develop. Examples of Susan’s coaching methodologies include:

•Asking direct questions

•Reflecting

•Active listening

•Offering praise and recognition

•Being candid, getting to the point

•Being nonjudgmental

•Being objective

•Challenging assumptions

8. Reassess and offer feedback. This reassessment phase is typically integrated into the implementation phase. If mentors are utilized, connection with them is appropriate for integration into the plan. Feedback should be consistent and close to the event that prompts the need for feedback.

In this example Susan is able to provide feedback to Don as she makes direct observation of team meetings and as she observes his staff. Susan talks about her observations and coaches Don to high-level solutions that impact his communication style. Susan also connects with peer mentors who provide direct feedback.

9. Evaluate. Evaluation is provided by the manager to gauge the success of the coaching. This phase is necessary to determine whether the developmental need has been met. Some questions that Susan asks Don are:

•What are you doing differently because of our interaction?

•What areas of need do you still want to focus on?

•What help do you need from me?

In addition, Don and Susan discuss the 360° reviews requested at different points in the coaching relationship and data points such as turnover and length of stay.

This evaluation reveals that Don believes the coaching has been a success, but Susan perceives that the skills have not yet been solidified. At this point, Susan focuses on Don’s resistance and his readiness to have Susan focus her energy on other employees. Don does overcome his resistance, and continues to focus on action plans.

10. Create closure. Success is determined by those engaged in a coaching relationship, both the coach and the coached. Remember, the coachee has the option to succeed or opt out. Susan and Don’s outcome is successful because of the established relationship and their shared commitment to success.

Appendix ACarilion’s Scorecard Model

The balanced scorecoard for Carilion.

There is a cause-and-effect relationship between the perspectives.

Appendix BCarilion’s Management Performance Appraisal

Carilion Health System
Level 4 & 5 Performance Appraisal Tool

FY 2005

Overall Summary

INSTRUCTIONS

Evaluate the performance of the leader during the past review period according to the criteria outlined in this document. Narrative information is necessary to support numerical ratings indicating Significantly Exceeds Expectations or Needs Significant Improvement.

Rating Scale:

1—Needs significant improvement.

3—Meets expectations.

5—Significantly exceeds expectations.

A.

Value Perspective

Overall Rating: ____

Applies key financial concepts and analysis to decision making. Develops and implements actionable work plans with measurable outcomes. Continually assesses and reallocates resources to meet demands.

Competencies to consider in rating performance and developmental goal planning:

•Financial Acumen. Understands drivers of financial performance and takes these into account when making decisions.

•Accountability. Meets agreed upon commitments

•Constructive Thinking. Analyzes problems systematically and logically, and is resourceful in developing and implementing solutions.

•Process Management. Develops key initiatives, measures, and targets appropriate to individual business unit. Proactively monitors key performance indicators and adjusts operations to achieve established targets.

Behaviors

Meets expectations:

•Establishes realistic budget using financial and quantitative information. •Manages budget by monitoring revenue and expenses, takes action to maintain budget and stay within established variances.

Susan H. Gebelein, Lisa A. Stevens, Carol J. Skube, David G. Lee, Brian L. Davis, and Lowell W. Hellervik, The Successful Manager’s Handbook, 6th ed. (Minneapolis: Personnel Decisions International, 2000).

The authors extend credit and thanks to Eyde Adams, Education Consultant, Carilion Health System; Debbie Copening, Education Consultant, Carilion Health System; Becky Dooley, Education Consultant, Carilion Health System; Linda Gardner, Education Consultant, Carilion Health System; Lori Griffith, Human Resources Assistant, Carilion Health System; Kim Hall, Education Consultant, Carilion Health System; Amy Hoots-Hendrix, Employee Communications Consultant, Carilion Health System; Charlotte Hubbard, Education Consultant, Carilion Health System; and Kay Trivett, Director, Med-Surg Unit, Carilion Health System, for their contributions.

	•Analyzes data before acting and considers financial impact of decisions.
	•Proactively reviews and revises staffing plan to best align human resources against operations, customer demands, and new initiatives.
	•Meets margin and scorecard goals.
Significantly exceeds:	•Financial impact has exceeded scorecard goal.
	•Implements initiatives with sound financial decisions that impact Carilion Health System’s bottom line.
	•Utilizes cost/benefit analysis and/or ROI to maximize financial position of business unit.
	•Mentoring others in financial acumen.

Achievement of Scorecard Goals/Projects: ____

Customer Perspective

Overall Rating: _____

Holds self and team accountable for maintaining the highest possible performance standards, serves a diverse group of customers (patients, employees, physicians, colleagues).

Competencies to consider in rating performance and developmental goal planning:

•Service Orientation and Customer Focus. Takes customer needs into account when making decisions

•Building and Strengthening Relationships. Builds and maintains long-term relationships based on mutual respect and trust, works toward solutions and compromises that consider the needs of all

Behaviors

Meet expectations:	•Customer satisfaction scores reflect continuous performance improvement.
	•Promptly resolves patient/customer concerns.
	•Role-models customer-focused behaviors for staff.
	•Cultivates relationships with stakeholders.
Significantly exceeds:	•Builds coalitions with internal and external customers to advance system initiatives and scorecard goals and to achieve Carilion Health System Mission/Vision.
	•Reviews and acts on market data to adjust operations and/or develop new business.
	•Continually strives to exceed customer expectations and to be the provider of choice.

Achievement of Scorecard Goals/Projects: ______

Internal Perspective

Overall Rating: ____

Delivers efficient, consistent, and timely services. Recognizes and acts on opportunities for growth and improvement to advance goals of the organization. Utilizes project management principles to accomplish goals, seeks out appropriate resources, and proactively anticipates change within the market, industry, and healthcare system. Aligns service with the Mission/Vision of the organization. Translates system goals into department specific objectives and priorities.

Competencies to consider in rating performance and developmental goal planning:

•Project Management. Implements a formal approach that highlights critical action items, accountabilities, and due dates

•Performance Improvement. Understands the business of healthcare, analyzes market trends, benchmarks with others, and makes improvements in internal operations

•Upward Management. Regularly updates manager on status of projects, provides information on items of concern to minimize risks and resolve problems

•Initiative. Acts on opportunities for growth and advances of the organization, confronts problems quickly

•Prioritizing and Delegating. Identifies and implements processes that facilitate delegation and shares responsibility with others

•Managing Vision and Purpose. Formulates plan to reflect needs of own area and those of the organization, relates the global vision to daily operations for team, assists with setting of priorities, and provides direction to ensure success.

Behaviors

Meets expectations:	•Demonstrates basic project management skills and meets project expectations.
	•Upholds commitments to others.
	•Links scorecard metrics to daily operations.
	•Streamlines processes to enhance daily operations and customer satisfaction.
	•Delegates appropriately for skill match and best outcome.
	•Creates actionable work plans for staff in order to achieve goals.
Significantly exceeds:	•Meets or exceeds established scorecard metrics.
	•Develops process enhancements that improve patient care and decrease operational costs.
	•Creates vision/direction for each business unit.
	•Takes initiative to propel business unit toward best in class practice.

Achievement of Scorecard Goals/Projects: ___

Learning and Growth Perspective

Overall Rating: ____

Inspires enthusiasm and builds support for projects. Attracts, selects, develops, and retains qualified employees, and is effective in utilizing developmental planning to expand employee skills and abilities.

Competencies to consider in rating performance and developmental goal planning:

•Identifying and Recruiting Talent. Attracts outstanding staff from diverse backgrounds and fills gaps in team skills and knowledge.

•Developing and Retaining Talent. Establishes developmental goals for skill development, offers stretch assignments, provides necessary coaching and education

•Giving Feedback. Shares advice and insight on progress toward program goals and objectives, provides performance feedback that is constructive and actionable

•Communicating Effectively. Articulates logical arguments, matches communication style of a message to the audience, solicits input from others, expresses ideas clearly, responds to concerns in a timely manner

•Motivating and Influencing. Generates commitment and buyin from a diverse staff on projects.

Behaviors

Meets expectations	•Develops retention plans.
	•Consistently follows Carilion’s employment process.
	•Utilizes interviewing techniques to assess skills and ensure right fit.
	•Utilizes resources to develop appropriate orientation process.
	•Develops education plans to target gaps in skills and knowledge.
	•Accepts accountability for creating environment that fosters retention.
	•Utilizes central education dollars based on prioritized needs.
	•Creates and maintains dependable methods of communication (monthly staff meetings).
	•Uses developmental planning as a tool to meet staff and unit goals.
	•Meets established target for turnover rate.
	•Utilizes performance management as a tool to develop staff and self.
Significantly exceeds:	•Role-models for and mentors others in recruiting and retaining the most appropriate people.
	•Proactively works with HR contacts to support recruitment and development efforts.
	•Creates challenging work environment that rewards risk-taking and skill development.
	•Implements succession planning and encourages new leaders to emerge.
	•Department retention plan offers a variety of recognition methods and strategies to address employee concerns and needs and departmental improvement opportunities; implements, evaluates, and revises routinely.
	•Implements coaching and follow-up techniques on employee development; engages employee accountability for improvement.

Achievement of Scorecard Goals/Projects: ____

B.

Service Standards

Promotes Carilion’s Culture of Excellence and quality service through encouraging teamwork; fostering open, honest communication; maintaining a professional environment; respecting others; and anticipating customer needs.

•Teamwork

•Communication

•Physical EnvironmentOverall Rating:

•Respect for Others

•Quality

Overall Rating: ____

Behaviors

Meets expectations:	•Anticipates team needs and works cooperatively to accomplish goals together.
	•Acknowledges/respects diversity of each team member.
	•Is supportive of giving/receiving constructive feedback in a team environment.
	•Resolves conflicts privately, taking care not to embarrass or criticize in front of others.
	•Utilizes core communication skills effectively.
	•Demonstrates honesty and integrity in everyday communication.
	•Is accountable for creating positive and productive work environment.
	•Respects all aspects of diversity.
	•Discourages gossip, rumors, and inappropriate language and behavior.
	•Consistently strives to produce a quality product and meet customer expectations.
Exceeds expectations:	•Role-models service standards consistently, coaches others to a higher level of performance.

Comments: ____________________________

1.360° Feedback (attach summarized feedback) (if applicable)

2.Required In-services (attach copy)

3.Licensure, certifications, CMEs, etc. (attach copies)

5.Signatures:

PERFORMANCE PLAN

Managers are knowledgeable and accountable for utilization of policies and procedures that direct Carilion Health Systems processes, and they are accountable for providing educational resources to employees on policy and procedure utilizaiton.

Appendix CAction Plan

1.Carilion’s Performance Plan Process

2.Carilion’s Performance Planning Document

3.Example of Performance Plan with Operational and Developmental Examples

1.Carilion’s Performance Plan Process

As a performance is discussed at the annual review, it often becomes apparent that additional skill development is required or desirable. Employee performance has demonstrated that there is a need for improved skills or that the employee is ready to take on additional responsibilities that require knowledge and skill acquisitions.

A performance plan is a tool that guides the individual as she strives for personal and professional growth. The plan should assist the employee in enhancing areas that need improvement and in developing new competencies.

The performance plan is developed jointly between employee and manager. Goals are established and action steps are identified that will guide the employee in meeting the goals.

When readying employees for their annual performance appraisal, the manager should encourage them to come to the review prepared to discuss their performance

After completing the performance appraisal tool, utilize the performance plan to guide the process.

Step 1:	Review goals from the previous year. Determine whether these goals were achieved. If they were not achieved, evaluate whether they are still current for the upcoming year.
Step 2:	Be sure that goals are smart. Goals can be short range or long range. Goals with time frames are easier to measure and to evaluate. The more specific a goal is, the easier it is to develop an action plan to meet the goal. Goals should be thought of as a “statement of intent.” Goals should be written with regard to employee’s performance and behaviors. Once you have transferred any goals that are being carried over from the most recent performance period, identify additional areas that need improvement. Look first to see whether there are any significant responsibilities that received a rating of “Needs Improvement.” These need to be incorporated into the plan so that the employee will focus on meeting the expectations for this job responsibility by the next performance appraisal. Next, look to any new responsibilities the employee is ready to assume. Is there a need for training and developing? If so, build this education into performance plan.
Step 3:	Identify the action steps that will assist the employee in meeting the goal. Again, this should be done jointly. The manager is responsible for guiding this process and helping the employee identify available resources; however, the employee needs to be a part of this plan in order to “buy in.” The action steps should be thought of as ways to accomplish the goal. Action steps should include, but are not limited to, activities, resources, and time frames.
Step 4:	Follow up on action plans. Check with employee to see that she is completing the action steps. Assess what kind of assistance she may need or whether it is necessary to revise action plan. New circumstances may have developed that are impacting the developmental plan. Document any action taken to reflect the status of the developmental plan.

2.Carilion’s Performance Planning Document

PERFORMANCE PLAN

3.Example of Performance Plan with Operational and Developmental Examples

I. Scorecard:	Value/Growth
	Increase financials through M&A growth
Operational Goal:	Design and implement M&A plan
Assumption:	Proficient in skills
Developmental Goal:	Develop M&A knowledge

Action Steps

1.Research and understand M&A processes. Develop education plan for self, share with director, and implement plan.

2.Relate M&A process to HRD functions.

3.Develop M&A project plan for HRD functions.

4.Seek feedback from director regarding the plan.

5.Implement and evaluate the plan.

Assumption:	Needs development
Outcome:	Both operational and developmental goals end with the same outcomes.
II. Scorecard:	Value
	Meet financial goals
Operational Goal:	Meet financial goals

Action Steps

1.Increase revenue.

2.Decrease costs.

3.Decrease overtime.

Assumption:	Proficient in skills
Developmental Goal:	Meet financial goals by expanding healthcare knowledge related to finance.

Action Steps

1.Develop relationships with financial adviser to gain knowledge of adviser role.

2.Analyze and react to financial reports.

3.Identify, monitor, and actively promote cost containment methods. Seek feedback from director.

4.Attend education-related budget methods.

5.Complete budget independently.

Appendix DCarilion’s Formal Coaching Definition, Model, and Process

1.Carilion’s coaching definition

2.Carilion’s coaching model

3.Carilion’s coaching process

1. Carilion’s Coaching Definition

Carilion defines coaching as an active process that promotes and brings about change in an individual’s thoughts, attitudes, and behaviors related to agreed-upon performance expectations.

2. Carilion’s Coaching Model

3. Carilion’s Coaching Process

1.Establish the need (review and performance plan).

2.Create a relationship.

3.Evaluate readiness for change.

4.Determine commitment to coaching.

5.Use discovery and observation.

6.Establish the plan: specific action strategies.

7.Implement the coaching plan.

8.Reassess and offer feedback.

9.Evaluate.

10.Create closure.

Be aware of and ready to deal with resistance during any phase.