How to Manage Underperformance in a Healthcare Team

• Underperformance should be understood before it is managed.
• Capability, confidence, conduct, workload, health, systems and unclear expectations can produce similar outward problems.
• Patient-safety concerns may require more immediate action than ordinary developmental concerns.
• Early, specific conversations are usually easier and fairer than waiting until problems become entrenched.
• Support and accountability are not opposites.
• Leaders should focus on observable behaviour and impact rather than assumptions about personality or motivation.
• Cross-professional concerns need to be addressed through the appropriate professional and managerial structures.
• Formal escalation should follow local organisational processes where informal improvement is insufficient or the concern is serious.

The word underperformance can describe very different situations. A junior doctor may be clinically capable but have lost confidence after a difficult incident. A nurse may repeatedly struggle with a task because the process is poorly designed. A pharmacist may find a new responsibility difficult because they have not received enough training. A physiotherapist may be overwhelmed by an unrealistic caseload. A senior clinician may consistently behave in a way that makes multidisciplinary working difficult.

These situations may all create concern, but it would be a mistake to respond to them in the same way.

Effective performance management therefore starts with diagnosis. Leaders need to understand what is happening, how long it has been happening, what impact it is having and what factors may be contributing before deciding what intervention is appropriate.

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Capability and conduct need to be distinguished

Capability concerns arise when someone wants to perform effectively but does not currently have the knowledge, skill or competence required. These situations may respond to training, supervision, clearer expectations or additional experience.

Conduct is different. A person may understand what is expected and be capable of meeting the standard but repeatedly fail to do so because of behaviour or choices. Persistent lateness, refusal to follow reasonable processes or disrespectful behaviour towards colleagues may therefore require a different leadership response.

Confusing the two can be unfair. Treating a capability gap as misconduct may punish someone who needs support, while repeatedly treating a behavioural problem as a training issue may allow unacceptable conduct to continue.

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Systems can make competent people appear to perform badly

Healthcare leaders should also examine the environment around the individual.

A poorly designed referral system can create repeated delays. An understaffed ward may make timely completion of lower-priority tasks difficult. Conflicting instructions from different senior staff may produce apparent inconsistency. A new digital system may create errors because workflows were never redesigned properly.

Before concluding that an individual is the problem, leaders need to understand whether the surrounding system is contributing.

This does not remove personal accountability. It prevents organisations from repeatedly blaming individuals for predictable problems created by the way work is organised.

Not every performance concern requires immediate escalation, but concerns that may place patients at risk need a different level of urgency.

A pattern of delayed documentation, incomplete follow-up or poor communication may initially be addressed through clarification and support. A concern involving unsafe clinical decisions, repeated failure to escalate deterioration, serious prescribing errors or significant professional misconduct may require more immediate action to protect patients while the issue is investigated properly.

The leader therefore needs to distinguish between developmental concerns and situations where risk requires rapid intervention.

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Immediate safety and longer-term development are separate questions

A colleague may need their duties adjusted temporarily while a concern is clarified. That decision is about safety rather than punishment.

Once immediate risk has been managed, the organisation can then examine what happened, whether the issue relates to competence, systems, behaviour or another factor, and what should happen next.

Separating these questions helps leaders respond proportionately rather than either minimising risk or moving prematurely to judgement.

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Patient safety should not be used to exaggerate every concern

The opposite error also occurs. Describing every performance issue as a patient-safety concern can make ordinary developmental feedback feel unnecessarily threatening.

A missed administrative deadline and an unsafe clinical decision are not equivalent.

Good leaders maintain proportion. They take genuine risk seriously while allowing ordinary performance concerns to be discussed as part of normal professional development.

People cannot reliably meet standards that have never been made clear.

Healthcare environments are full of implicit expectations. Senior clinicians may assume that trainees understand how quickly results need to be reviewed. Managers may believe everybody knows who owns a particular action. Teams may assume that a new member understands local practice because the process seems obvious to people who have worked there for years.

Performance management becomes unfair when people are criticised for failing to meet expectations that were never properly communicated.

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Define the expected standard clearly

A useful performance conversation needs specificity.

Rather than saying that somebody needs to “be more organised”, explain which responsibilities are not being completed, what standard is expected and why it matters. Instead of telling a clinician that they need to “communicate better”, identify the behaviour that is creating difficulty.

Specific expectations give the person something they can act on and make subsequent review considerably fairer.

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Clarify responsibility at professional boundaries

Unclear expectations are particularly common where professions or services overlap.

A delayed discharge may appear to reflect poor performance until it becomes clear that nobody had agreed whether the medical team, pharmacy or discharge team owned a particular action. A follow-up may be missed because two specialties each believed the other was responsible. A ward task may repeatedly be delayed because responsibility shifts between nursing and medical teams without being explicitly agreed.

Before attributing failure to an individual, leaders need to establish whether ownership was genuinely clear.

Once concern develops about someone's performance, there is a natural risk of interpreting subsequent events through that concern.

A colleague who has acquired a reputation for being disorganised may find every delay attributed to them, including delays outside their control. Someone regarded as difficult may have legitimate disagreement interpreted as further evidence of poor behaviour.

Leaders need to resist this confirmation bias.

Performance management should be based on specific examples, patterns and impact rather than reputation or second-hand labels.

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Observable behaviour is more useful than personality judgements

Statements such as “you are unreliable”, “you lack commitment” or “you have a bad attitude” are difficult to respond to because they describe a perceived character rather than behaviour.

It is far more useful to identify what happened, when it happened and what effect it had.

For example, repeated failure to attend an agreed handover can be discussed. The impact on colleagues and continuity of care can be explained. The expected standard can then be clarified.

The conversation remains about something that can change.

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Patterns matter more than isolated imperfections

Healthcare professionals work in demanding environments, and occasional mistakes or missed tasks do not automatically indicate underperformance.

Leaders should consider frequency, severity, context and whether the same issue is recurring despite feedback.

This prevents ordinary human error from being labelled as poor performance while still allowing genuine patterns to be addressed before they become more serious.

Many leaders delay performance conversations because they hope the issue will resolve naturally or because they do not want to damage the relationship.

Minor problems sometimes do resolve. Persistent patterns usually become harder to discuss with time.

By the time a leader finally raises the concern, they may already be frustrated, while the individual may be surprised to discover that concerns have been accumulating for weeks or months.

Early conversations are generally fairer because they give the person an opportunity to understand and correct the problem before it becomes entrenched.

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Start with the concern rather than the conclusion

A useful early conversation should describe what has been observed and invite the person's perspective.

The leader may believe they understand why the problem is occurring, but the conversation may reveal information that was previously missing. A colleague who appears disengaged may be struggling with workload. Someone who seems indecisive may be working beyond their current confidence. Delays may reflect a process problem rather than lack of effort.

Listening does not mean abandoning the concern. It improves the likelihood of identifying the right response.

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Be clear enough for the conversation to matter

Leaders sometimes soften difficult feedback so extensively that the other person leaves without realising there is a significant problem.

A supportive conversation still needs clarity. The individual should understand what the concern is, why it matters and what needs to improve.

Being respectful and being vague are not the same thing. Clear communication gives the person a genuine opportunity to respond.

Not every decline in performance reflects a loss of competence.

Healthcare professionals may become more hesitant after a serious incident, complaint, difficult clinical outcome or period away from practice. They may repeatedly seek reassurance, avoid taking responsibility or escalate decisions they previously handled independently.

From the outside, this can look like underperformance. The underlying problem may be confidence rather than knowledge.

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Support should rebuild independence rather than create dependency

When confidence is the issue, repeated reassurance can help in the short term but may inadvertently reinforce dependence on senior colleagues.

A more developmental approach combines appropriate supervision with gradually increasing responsibility. Coaching, focused feedback and opportunities to succeed in manageable situations can help restore professional confidence.

The objective is to support the person back towards safe autonomy.

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Confidence problems still require standards

Understanding the cause of the difficulty does not mean expectations disappear.

Patient care still needs to be safe, and the colleague may temporarily require more supervision or a different level of responsibility.

Supportive leadership combines empathy for the individual's situation with clarity about what safe practice requires.

Healthcare performance takes place within a system.

A professional who is repeatedly unable to complete everything expected of them may have a performance problem. They may also have been given an impossible workload.

Leaders need to distinguish between an individual's difficulty with organisation or prioritisation and a service that is routinely asking people to complete more work than can reasonably be delivered.

Failure to make this distinction creates unfairness and can conceal wider organisational risk.

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Compare expectations with available capacity

Where several members of the same team are struggling with the same task, the probability of a system problem increases.

If documentation is repeatedly late across an entire service, the issue may be workflow rather than individual discipline. If staff cannot attend training because clinical activity leaves no protected time, repeated reminders are unlikely to solve the underlying problem. If referral delays occur across several specialties, the process itself may be poorly designed.

Good leaders examine whether the expected standard is realistic within the current resources and systems.

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System problems do not remove individual responsibility

A pressured system can explain why performance is difficult without making all behaviour acceptable.

Healthcare professionals still need to prioritise, communicate when they cannot meet expectations and escalate risks appropriately.

Leadership therefore needs to address both sides: improve the system where necessary while remaining clear about reasonable professional responsibilities within it.

Healthcare leaders often identify concerns involving colleagues they do not directly manage.

A consultant may be concerned about another doctor's repeated failure to complete agreed actions despite having no managerial authority over them. A nurse leader may have concerns about medical communication. A pharmacist may identify unsafe prescribing behaviour but not line-manage the clinician involved. A clinical manager may see a recurring performance issue involving a professional who reports through another structure.

The same challenge exists between medical specialties. A consultant in one department may experience repeated problems with referrals, communication or clinical ownership involving another service, while neither consultant has authority over the other.

Ignoring the concern because the colleague belongs to another profession or specialty is not appropriate. Neither is assuming authority that the leader does not have.

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Address the impact directly where appropriate

Professionals can usually discuss the practical effect of each other's behaviour without becoming the other person's manager.

A consultant can explain that repeated failure to provide agreed information is delaying care. A pharmacist can raise concerns about a recurring prescribing pattern. A nurse can describe how inconsistent communication is affecting the ward. One specialty can raise concerns with another about repeated ambiguity over patient ownership.

Keeping the conversation specific and focused on patients, workflow or team functioning makes cross-professional feedback more constructive.

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Formal concerns should use the appropriate leadership structure

Where a concern requires formal performance management, the relevant professional or managerial lead should be involved.

This respects accountability and ensures that processes are applied consistently.

Good multidisciplinary leadership therefore means working across leadership structures rather than pretending those structures do not exist.

Once the cause of underperformance is reasonably understood, the leader needs to agree what happens next.

A vague expectation that someone should “improve” is unlikely to be sufficient. The individual needs to understand what change is required, what support will be available and when progress will be reviewed.

This creates a fairer process for both the individual and the team.

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Improvement needs to be observable

An effective improvement plan focuses on specific outcomes or behaviours.

If communication is the concern, improvement might involve timely handover, clearer escalation or consistent documentation. If clinical capability is the issue, the plan may involve supervision, targeted training and evidence that defined competencies have been achieved.

Observable objectives make progress easier to assess and reduce disagreement later about whether improvement has occurred.

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Support should match the cause

The intervention should reflect the problem identified.

Training is appropriate for a skills gap. Coaching may help with confidence or judgement. Workload changes may be needed where capacity is the issue. Clear boundaries may be required for behavioural problems.

Offering the wrong form of support can prolong the problem while creating the appearance that something is being done.

Performance management is not only about the individual.

When one person repeatedly fails to meet agreed standards, colleagues often compensate. They complete additional work, correct mistakes, absorb extra shifts, chase unfinished actions or spend time resolving problems.

If leaders appear unwilling to address the situation, high-performing staff may become frustrated and begin to question whether standards are applied fairly.

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Unequal accountability affects morale

Teams pay attention to what leaders tolerate.

If one person's poor performance repeatedly creates additional work for others without visible action, the message is that meeting expectations may be optional.

This can damage morale more than the original underperformance itself. Staff who are consistently reliable may begin to feel that their effort is being taken for granted while poor performance attracts repeated accommodation.

Fair leadership therefore means considering the impact on colleagues as well as the needs of the individual concerned.

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Avoiding the issue can damage relationships rather than protect them

Leaders sometimes postpone action because they want to remain supportive or fear being perceived as confrontational.

However, refusing to address a problem can damage relationships across the wider team. Colleagues may become resentful, communication may deteriorate and frustrations may begin to emerge indirectly rather than through a constructive conversation.

The aim should not be to keep every individual comfortable. It should be to deal with concerns fairly, proportionately and respectfully.

When performance concerns persist, accurate documentation becomes increasingly important.

This should not be approached as building a case against someone. Its purpose is to create a reliable record of what was discussed, what expectations were agreed, what support was offered and what progress occurred.

Without documentation, both the leader and the individual may later remember conversations differently.

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Record facts and agreed actions

Useful documentation focuses on specific concerns, examples, impact, expectations, support and review dates.

It should avoid unnecessary emotive language or unsupported assumptions about motivation.

Clear records also help maintain continuity when several leaders, supervisors or professional structures become involved.

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Review should be planned rather than indefinite

An improvement process needs a point at which progress is reconsidered.

Without an agreed review period, concerns can continue indefinitely with neither the individual nor the leader knowing whether the situation has improved sufficiently.

Review creates an opportunity to recognise genuine progress, adjust support where necessary or consider further action if improvement has not occurred.

Many performance concerns can be resolved through early feedback, support and clear expectations. Some cannot.

Formal escalation may become necessary where patient safety is at risk, concerns are serious, behaviour is unacceptable or improvement does not occur despite reasonable support.

At that point, leaders should follow the appropriate organisational process and involve relevant HR, professional, educational or clinical leadership structures as required.

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Formal action should not come as a surprise where avoidable

Except in situations requiring immediate intervention, an individual should generally know that concerns exist before they reach a formal stage.

Repeatedly hinting at a problem without clearly discussing it and then suddenly escalating formally is poor leadership.

Early clarity gives the individual a fair opportunity to respond and makes any later escalation easier to understand.

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Formal processes can protect everyone involved

Formal performance procedures are sometimes viewed solely as mechanisms for dealing with the person underperforming.

They also create consistency, documentation and safeguards for the individual, the leader, colleagues and patients.

Leaders should therefore neither rush unnecessarily towards formal processes nor avoid them indefinitely when they are genuinely required.

Underperformance is difficult to manage well because several leadership instincts can pull in unhelpful directions.

One common mistake is waiting too long. Another is moving to judgement before understanding the cause. Some leaders become so supportive that expectations disappear, while others focus so heavily on accountability that they fail to identify obvious system or training problems.

The quality of performance management depends on holding these considerations together.

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Avoid solving the wrong problem

Training will not solve wilful poor behaviour. Formal discipline will not fix an impossible workload. Reassurance will not correct a genuine capability gap. Coaching will not resolve a badly designed system.

The intervention needs to match the cause.

This is why the diagnostic stage of performance management matters so much.

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Avoid making the issue personal

Performance conversations become much harder when the leader begins to view the individual themselves as the problem.

Focusing on specific behaviour, standards and impact preserves greater objectivity and gives the person something they can change.

The aim should be improved performance and safe, effective teamwork rather than proving that the leader's negative impression was correct.

Managing underperformance well requires judgement rather than a single technique.

Leaders need to recognise when the problem is capability, behaviour, confidence, workload, unclear expectations or the system itself. They need to protect patient safety without overreacting, support colleagues without allowing standards to disappear and know when informal leadership needs to become formal management.

Done well, performance management is not primarily punitive. It creates clarity, supports improvement and protects both patients and teams.

The strongest healthcare leaders do not wait until underperformance becomes a crisis. They create a culture in which expectations are clear, feedback is normal and concerns can be discussed early enough for improvement to remain realistic.