Dr Vasumathy Sivarajasingam Advocates Uptake of a Feedback Technique for Improving Individual and Organisational Performance
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Find implementation actions for clinical pharmacists in general practice at the end of this article
Feedback is a core aspect of any organisation’s learning culture and, when offered constructively, it can be beneficial for all staff members. Feedback can be given in a variety of ways, and can be informal or formal, verbal or written, and in a paper or digital format—the approach depends on organisational preferences. The opportunity for reflection that feedback offers can assist organisations to develop ideas about what positive changes are needed, and how those changes may be achieved.
Healthcare organisations face a unique set of challenges when it comes to evaluating performance and understanding developmental needs, as managers must assess both the clinical and nonclinical skills that contribute to the organisation’s overall success. Feedback can play a significant role in understanding those aptitudes that are not directly related to job-specific skills, and the process of giving and receiving feedback is an opportunity to identify strengths and areas for improvement.1 In healthcare specifically, feedback is particularly effective for highlighting development areas and prompting clinicians to reflect on their performance,2 and its use is considered to improve employee engagement3 and service quality.4 Overall, effective utilisation of feedback can enhance the self-awareness of and communication between team members and, ultimately, improve team performance.5
As a concept, 360-degree feedback—also known as multisource feedback—dates back to the 1950s, when many organisations saw a need to improve communication within their development and review processes,5,6 and its use has been widespread outside of healthcare for decades.7,8 There has been an international drive to implement the system in healthcare for many years,7 and the technique has been trialled in the NHS since the turn of the millennium.8 However, although several studies have demonstrated the reliability, feasibility, and validity of 360-degree feedback when used in a healthcare setting,7,9 there is a lack of evidence on how to design and deliver an effective 360-degree feedback process.7
This article provides a broad overview of 360-degree feedback, outlining how effective use of the technique has the potential to enhance personal and organisational development in a primary care setting.
What is 360-degree Feedback?
The 360-degree feedback process is one in which feedback is gathered from various people who work, or have regular contact with a particular member of staff.1,5,10,11 The technique utilises the opinions of multiple reviewers, including peers, subordinates, and supervisors, in conjunction with the individual’s own self-evaluation.5,10,11
Initially, the 360-degree feedback process relied heavily on ‘upward feedback’—from supervisee to supervisor—and struggled with reliability and validity.5,6 Over time, however, the technique has evolved to include multiple reviewers,5,11 which is key to its value: consulting numerous stakeholders has been shown to lead to higher-quality feedback, in terms of validity and reliability, than when a single source is consulted.11–14 The intention is for the individual to receive feedback that is comprehensive and productive, yet confidential and anonymous, from a ‘full circle’ of colleagues.5,11,13
This feedback is then collated, reported to the reviewers and the reviewee, and used as a development tool, with the aim of revealing the reviewee’s strengths and weaknesses, and enabling them to work on these areas.1,15,16 It may seem useful to incorporate this feedback into more formalised performance evaluations, but this is cautioned against because an association with performance rating, pay, or promotion can have a negative effect on the honesty of reviewers’ responses.11,16
The feedback gathered focuses on how an individual performs their duties—how they achieve their goals and how they are perceived by others—rather than on any particular outcome or target.1
What are the Benefits of 360-degree Feedback?
The 360-degree feedback process can have many benefits for the individual, team, and organisation—from improved communication, to greater organisational transparency and better employee development.1,5,11,17 It is particularly useful for assessing less quantifiable skills, such as leadership or teamwork, which are essential for an individual’s career development.18 For this reason, development and appraisal are two areas in which this type of feedback can be especially useful.18
The peer evaluation afforded by 360-degree feedback provides an individual with multiple perspectives outside of their own, giving them a well-balanced view of their behaviour and skills.1,5,19,20 The resulting self-awareness is a key benefit of the 360-degree feedback process, as it reveals others’ perceptions to an individual, and enables them to recognise strengths and weaknesses that they were perhaps unaware of.1,5,21 Self-awareness has been linked with improved behaviour and performance at work and, in turn, overall team performance.17,22
This kind of self-awareness is particularly beneficial for those in leadership roles,1,14 as it shows them how much they inspire, motivate, and support those they manage. An added benefit is that the process of giving feedback provides reviewers with the opportunity to reflect on their own behaviour.5,17,23
Improving Communication and Transparency
Another advantage of 360-degree feedback is an increase in communication between team members.5,13,24 This improved communication is facilitated by the anonymity of the process—having the opportunity to anonymously review coworkers leads to more honest feedback, particularly when the reviewer is the subordinate of the reviewee.5,11,13,16
Coworkers who have been through this feedback process together are less likely to be defensive in the face of criticism,15 and more likely to be aware of each other’s strengths, weaknesses, perspectives, and expectations.5,13,24 The introduction of 360-degree feedback therefore promotes an open culture, as each team member is able to voice their opinion.1 This improved communication can lead to improved performance,5 and thus improved quality of care and patient satisfaction.
The process can also help to reduce managerial biases, which are often prevalent in more traditional feedback processes that only incorporate the perspective of an employee’s manager.11
Encouraging Personal and Professional Development
Honest, reliable feedback allows a person to challenge their own perceptions, and as such is an essential tool for supporting career growth.1 Everyone has something they can improve upon, and the opinions of others, freely given, are essential for fine-tuning behaviours and goals.1
Collectively, this kind of feedback can also be a great way to identify staff training and skill development needs20 —particularly if similar issues keep arising in different feedback sessions.
Reinforcing Colleagues’ Appreciation
Comprehensive feedback—both positive and negative—effectively enables staff to see how they are viewed in an organisation.19 With our busy schedules in primary care, we often fail to share positive feedback with our colleagues. The 360-degree feedback process may help to overcome this barrier, giving individuals the opportunity to see first hand that their hard work is recognised by the rest of the team.
What are the Challenges Associated with 360-degree Feedback?
It is important, however, to be mindful of the challenges inherent in implementing 360-degree feedback. Asking the wrong questions or implementing the process poorly can cause disharmony in a team;25 for instance, by undermining staff members or causing hurt or confusion. If the process is not implemented well—for example, if the reviewers do not know their reviewee very well, managers are not invested, anonymity is not ensured, or feedback is framed poorly—it can be more harmful than helpful.19,20,26
In addition, it may be easy for the process to become focused on negative feedback, so a prompt change to the process is needed if staff show symptoms of a toxic outlook.19 This issue may be particularly prevalent in healthcare organisations, possibly because of the significance of any mistake made in these settings—clinicians’ emotional reactions to negative feedback have been shown to make them less likely to act upon it.27
Before launching the feedback process for a team, it is also important to consider costs, including both time-related (length of assessment and evaluation of data) and monetary expenses—it can be a time-consuming process,14,20 and the cost of consultants, software, and training can be quite significant.11,25
Is 360-degree Feedback Right for Your Practice?
Before implementing a 360-degree feedback system, it is essential to determine whether this type of feedback process is right for the organisation.5,11 It is recommended that a team should be well-established before it adopts a 360-degree feedback system—around 1.7 years, according to one study.5,12 This delay theoretically allows members of staff to get to know one another,5 and therefore give more accurate feedback. Further factors that it may be useful to take into account before adopting a 360-degree feedback process include levels of trust, stability, and commitment in the team, as these considerations may also have significant positive or negative impacts on the outcome.5,12
How to Implement the 360-degree Feedback Process
Anonymity and impartiality should be established early in the implementation of 360-degree feedback, as they will encourage staff to give honest responses.11,13,16 I would suggest agreeing a minimum and maximum number of reviewers, as well as ensuring that there is a sufficient number of them to protect confidentiality. A sensible suggestion may be to have at least five reviewers providing feedback.5,22 It may be beneficial to balance this number with the time taken to conduct the process: the more reviewers involved, the longer the evaluation will take.
Both reviewer and reviewee must feel that the process is fair and honest.5,25 Fairness can be achieved by including several people in the selection of reviewers, not just the reviewee’s line manager.5,28 For the feedback to be meaningful and valuable, it is best if the chosen reviewers have worked closely with the individual being assessed for a substantial period of time—6 months is a suggested timeframe.11
Questions and Competencies to Include
The feedback in this process is usually compiled using a competency-based questionnaire given to the reviewee and their reviewers, with scored questions based on frequency (‘How often does Dr Smith do X?’) and quality (‘How well does Dr Smith do Y?’), or based on key competencies for the individual and organisation.11,13,29 The specifics can vary, but it is suggested that the questions cover around between eight and twelve key competencies.1,11
Each organisation is unique in terms of its culture, characteristics, and leadership needs, so feedback should be tailored to the organisation.18 For specificity and relevance, the feedback questionnaire should include questions covering a wide range of workplace competencies, skills, and behaviours that complement the organisation’s goals and values. Some example competencies are included in Box 1.11,13,18,25
|Box 1: Example Competencies to Include in 360-degree Feedback11,13,18,25|
Organisation and Planning
Knowledge and Understanding
The questions could invite written comments, or use a rating scale. Nonspecific, open-ended questions about an individual’s performance may not be particularly helpful, however, as they are likely to elicit different answers depending on the respondent.11 For example, the question ‘How well does the person listen to and consider other people’s views?’ will yield more constructive data than the question ‘What is your experience of interacting with the person?’. For the feedback to be effective, questions should aim to identify specific behaviours that are associated with the overall goals of the organisation, as the wrong questions could make a reviewee confused about their role and purpose within the team.5,28
As a form of self-evaluation, it is useful for the individual receiving feedback to complete the survey as well—this will likely support their motivation to improve.5,13,25
Timeframe and Frequency of the Process
Once a survey is sent to reviewers, monitor responses and give a realistic deadline for completion. A standardised timeframe for collecting feedback will likely be most effective: consider 6–12-month intervals, as this allows teams to assess themselves and see how they have progressed.5,13,22
The Importance of Effective Communication
A successful 360-degree feedback process relies upon everyone involved having a thorough understanding of the process. The following sections suggest some areas to cover when discussing the 360-degree feedback process with the participants.
Discuss the Purpose of the Assessment
It is essential to explain to staff what 360-degree feedback means for both organisational and personal development, and the importance of giving constructive feedback. Clear communication of the intent and purpose of the feedback process can help to preclude common issues such as dishonest responses or distrust of the system.5,19,20 It must be stressed that this is not an opportunity to criticise, but rather a chance for individuals to learn and develop.
Emphasising and ensuring the anonymity and confidentiality of the process is especially important to prevent insincere reviews that are driven by a fear of conflict or retaliation.11,25 If staff members feel that their responses will not remain confidential, concerns about retribution and negative consequences may reduce their candour.11,13,19,25 Using a third party to process and organise results is one way to avoid this.13
Explain How to Give Feedback
It is important to provide guidance on how to give constructive feedback that is based on reviewers’ experiences with the reviewee.5,11 Ideally, one experience should not overshadow all others, and feedback should be based on a holistic view of the person; encouraging reviewers to give examples of what the person does well and what they could do differently can be very useful.
Share Feedback Reports and Implementation Plans
Explaining how the feedback will be used once it is collected is key to the transparency of the process.5 Failure to communicate the outcome of feedback, or to provide a follow-up plan, may lead to a lack of trust in the system or a belief that the feedback will not be used.5,28 Reviewers may also be reluctant to give honest feedback if they do not know how their feedback will be used, particularly if they are unsure whether it is purely for personal development or will inform performance or compensation reviews.5,28
Orienting Around Goals and Expectations
It is widely accepted that 360-degree feedback is most effective when it is centred on the behaviours and skills that most align with the organisation’s values and objectives.5,13 Having a clear vision and direction, which is shared openly with the whole team, can help to ensure that everyone is working towards a common goal.
Understanding how members of staff are evaluated may also help an individual to understand the overall aims of the team and organisation, and to align their self-improvement goals accordingly.5 People are also more likely to change their behaviour if 360-degree feedback is combined with specific performance goals and areas for improvement.5,22,23,25,26
Acting on the Feedback
It is pointless collecting feedback with little or no follow up—feedback should be acted upon. When staff members are provided with adequate resources for improvement, and held accountable to a commitment to change, they are more likely to act.11,25,30
Feedback can be interpreted in a variety of ways, so it is important to establish a framework for delivering this feedback that is consistent and effective.5 An evaluation of the report should be shared with the individual and an action plan developed, including discussion of their next steps for improvement. This report could be compiled internally or externally.5 Ideally, those who are involved in delivering 360-degree feedback results should have formal training on:5,25
- interpreting results
- identifying team members’ strengths and weaknesses
- giving negative feedback
- developing action plans for sharing feedback and working towards established goals.
Embedding 360-degree Feedback to the Top of the Organisation
One of the advantages of this method of providing feedback is that it is an effective way to provide leaders with information and perspectives different from their own.1,26 Leaders who are engaged and invested in this feedback process, both for themselves and others, will hopefully also be engaged in becoming better managers, and improving the workplace in the process.26
Box 2 provides an example of areas covered in a GP partner’s anonymous 360-degree feedback form. The form was shared with the practice team using SurveyMonkey®, and is an example of a simple, inexpensive format for assessment.
At this particular surgery, 360-degree feedback was developed as part of the organisation’s 5-year plan, and has been in place for over 3 years. The GP partners’ roles and responsibilities (both clinical and nonclinical), partnership agreement, and 5-year plan were reviewed, and the topics in Box 2 were chosen as key qualities required of a leader at the practice. The feedback is collected annually, and is in addition to the formal feedback, from staff and patients, involved in revalidation.
|Box 2: Hillview Surgery GP Partner 360-degree Anonymous Feedback Form|
Portfolio—Clinical and Nonclinical
Leadership Skills (Innovative Ideas and How to Make a Difference)
Effective utilisation of 360-degree feedback in primary care settings can promote self-awareness in team members and foster a cohesive workforce by improving trust, openness, and clarity about expected goals and behaviours. The process can support the personal and professional growth of staff members, and is a good basis for helping individuals to become better employees and leaders.
Done well, 360-degree feedback is impartial, and assesses attributes other than job-specific skills. However, it should not be taken lightly. Rather, it offers a valuable opportunity to consider the characteristics of the individual and the team, the goals of the organisation, and any long-term objectives and activities needed to sustain them. These considerations are essential for the implementation of any people-driven scheme, and are just as applicable in healthcare as they are in any other setting.
|Implementation Actions for Clinical Pharmacists in General Practice|
Written by Anjna Sharma, Director of Workforce Transformation, Soar Beyond Ltd
Both clinicians and nonclinical managers are now expected to be simultaneously leaders and members of the MDT. Consequently, it can be challenging to ensure that new ARRS staff are integrated, embedded, and supported to work safely and competently to the top of their licence.
One area in which improvement has the potential to support the integration of ARRS staff is the standardised feedback and performance-development process. If not implemented consistently across the organisation, poor motivation and retention of staff may result. This was highlighted in a recent report by The King’s Fund, which emphasised the lack of belonging and integration experienced by new ARRS staff.[A]
Soar Beyond Ltd is assisting PCNs to support, embed, develop, and retain their MDT workforce using the innovative SMART Workforce platform;[B] its implementation advice to managers is to:
To find out more about how Soar Beyond Ltd is supporting teams to embed performance development and a 360-degree culture, visit www.thesmartworkforce.com.
MDT=multidisciplinary team; ARRS=Additional Roles Reimbursement Scheme; PCN=primary care network
[A] Baird B, Lamming L, Bhatt R et al. Integrating additional roles into primary care networks. London: The King’s Fund, 2022. Available at: www.kingsfund.org.uk/publications/integrating-additional-roles-into-primary-care-networks
[B] Soar Beyond Ltd. SMART Workforce. soarbeyond.co.uk/services/healthcare-services/smart-workforce/ (accessed 15 September 2022).
Dr Vasumathy Sivarajasingam
GP Partner, Hillview Surgery, West London