Solid teams help small practices navigate safely in uncertain times

Team cohesion and effective employee retention strategies allowed small ophthalmology practices to rise to the challenges of the SARS-CoV-2 pandemic and grow even stronger in some cases.

“We found lessons and new opportunities in the crisis. At first, we adapted to survive, but then we realized that some of the changes we had introduced were making us grow, and we will not revert back to the way we were,” Healio/OSN Board Member Neda Shamie, MD, said.

The year that followed the initial 2020 lockdown turned out to be best in 10 years for the Maloney-Shamie Vision Institute in terms of the number of patients seen and surgeries performed, with continued growth even after the initial patient backlog had been cleared.

“This was because we took the opportunity, during those 6 weeks of suspended activities, to fortify the foundations of our practice, improve our brand and strengthen our team. COVID opened our eyes to possibilities we would have never explored otherwise,” she said.

Virtual consultations and hybrid working

Shamie is co-owner of a single-site private practice in Los Angeles, a tertiary type of center offering LASIK, advanced cataract and corneal surgery.

“We have a very robust, established practice, a well-known brand, with employees that have been there for 10 or 20 years thanks to the practice’s founder and managing partner, Dr. Robert Maloney. What attracts them to come and stay with us, in a very competitive environment where there are plenty of other options, is that we value their potential and offer opportunities for growth within the practice,” she said.

At the start of the pandemic, Shamie and Maloney gathered their team to discuss new ways to work efficiently and effectively while mitigating the spread of the virus. Virtual consultations were introduced and have now become an important part of the practice as an effective way to optimize time and resources and reduce patient burden without affecting outcomes.

“I am quite convinced that if we had switched to virtual consults before COVID, it would not have had any traction. With COVID, and the fact that the entire world was forced to become accustomed to virtual platforms of connecting, it was embraced and offered an alternate approach to stay afloat. What was initially a means of survival and could’ve been abandoned became an opportunity to explore. We seized that opportunity and have embraced it as an added tool for growth in our practice. If you take a moment and evaluate the protocols we follow, you will find inefficiencies in the way we manage patient care. Examples of such inefficiencies are in the number and frequency of follow-up visits we routinely schedule. We looked at our protocols and saw an opportunity to either eliminate unnecessary visits or convert some to virtual follow-ups. When we initiate a dry eye treatment regimen, we were asking patients to return for a follow-up at the 3- to 6-week timepoint and often found ourselves modifying the treatment not based on the exam findings but rather the symptomatic feedback and OSDI score reported by the patient. Here was an opportunity to eliminate an in-person visit and instead offer a virtual follow-up that was sufficiently effective in monitoring patient response to treatment and encourage compliance,” Shamie said.

Another change introduced in her practice involved moving some of the staff to a virtual or hybrid model of work.

“A few of our staff members now work entirely from home, and a few work 2 days at home and 3 days in the office,” Shamie said.

Again, this change came out of necessity, mainly due to the child care challenges created by school closures at the early stages of the pandemic.

“When one of our key employees shared with us her inability to return to work as she needed help at home, we pivoted to a hybrid work environment,” Shamie said.

Employees who were facing these problems and worked in a capacity amenable to virtual working were given the opportunity to work from home, and this has become an effective staff retention strategy.

“We live in a very traffic-congested area in Los Angeles, and many of our staff have to drive 1 to 2 hours to get to work. Hybrid working has allowed us to improve the work-life balance for some of our team members, increasing their morale and motivation, and we are working toward increasing the number of our employees who can have more of such flexibility,” Shamie said.

So far, so near

Remote work should not necessarily break the mechanisms that allow a team to work together creatively, according to Shamie. Her practice has adopted Sneek, a group video conference software that is always on by default and allows the staff to immediately connect at any time during office hours.

“It creates a virtual version of the hallway conversation, where you click on someone’s face on your screen, and then you have an immediate connection with them,” Shamie said.

It is also important for those who work at home to adopt a project-based model of work, with specific goals and deadlines.

“Our employees who work from home manage to stay efficient and feel that they may actually be more productive. They say they have less distractions, their mind is more focused, and they feel generally happier,” Shamie said.

Lisa K. Feulner, MD, PhD, owns a practice in which she offers a variety of vision care services, ocular surgery and aesthetics procedures. The pandemic situation made her lose 20% of her staff, mostly young mothers who had to homeschool their children or be at home with them when schools went online.

“Others had a tremendous fear of getting sick and no longer wanted to work in health care,” she said.

Her head scribe moved to Montana and was rehired remotely on a part-time basis.

“That was the best decision ever. She does remote scribing while I am examining the patient and a lot more. She does all the online and telephone communication with the patients and manages all their requests, instantly bridging with us through our medical record software. Whatever issue they have, whether it is a prescription refill, an appointment they cannot keep, spectacles they want to change, questions about cost and coverage of medications, she is there to offer troubleshooting and support. She also calls the patients to tell them the results of their tests when they are normal and schedules appointments,” Feulner said. “COVID caused us to have staffing gaps, and we filled in that gap much better than we would ever have done in the usual way.”

Respect and reward one another

Under the unusual circumstances created by the pandemic, staff replacement was carried out by direct referral, and this turned out to have many positive consequences, Feulner said.

“We incentivized our staff to refer people that they knew, and that’s worked really well for us because we get like-minded people who more easily embrace the culture of the practice, like and respect each other, and work hard with and for one another,” she said.

More than experience, Feulner values intelligence, personality, a positive attitude and an interest in growing.

“More than half of our technical staff have come in with no backgrounds but have turned out to be phenomenal and have found with us opportunities for professional development, sometimes fitting into roles they would have never imagined,” she said.

A good habit of her practice that has become even more important with COVID is to reward employees with frequent staff appreciation initiatives.

“Staff shortage has been very stressful on the people who are still here. They are working double hard, often overtime, and often sacrifice their personal time by canceling vacations. So, we do a lot of staff appreciation to celebrate them and recognize that they are doing so much,” Feulner said.

She personally thanks every person in the office at the end of each day, something that requires only about 15 minutes in a small-size practice with 30 employees. Her staff loves it, and it gives her the opportunity to find out if anyone is having problems she can help with.

One critical point in the way her practice is organized is a clear path of leadership, in which employees have knowledge of their direct chain of command. There is a supervisor for each division, and they are like “the spokes on a wheel,” Feulner said.

“The wheel rim is all of us, in the clinical, optical and aesthetics divisions. The supervisors are the spokes, and they feed into the clinical operation manager, so everybody knows who they’re supposed to go to. In this way, there is no confusion about what the rules are and where the feedback is coming from. If there are issues that the supervisors can’t handle, they can refer to me, but I never communicate my answer directly to the staff — it is always the supervisor,” she said.

Special projects generate energy

Healio/OSN Board Member Laura M. Periman, MD, is the founder and owner of a solo startup practice in Seattle. She opened in June 2020, in the midst of the pandemic, aiming at a specific target.

“We are very specialized in just dry eye and ocular surface disease, an area of growing interest during the current pandemic. High-level specialization attracts patients from a broad area in the U.S. and overseas,” she said.

In addition to routine clinical work, her team does clinical research studies and is working on creating a teaching program for colleagues who want an update on dry eye management.

Offering super-specialized, top-line clinical science and services to patients is a major key to the success of her practice, according to Periman. Special projects generate energy, an increased sense of contribution to the group and a strong sense of importance.

“Also, patients feel they are participating in something bigger, in a far-reaching project, and this has a spillover effect on care,” she said.

Engagement, empowerment, elevation, enthusiasm

Periman’s practice was built around a strong team mindset with shared values that she defined as “the four E's”: engagement, empowerment, elevation and enthusiasm.

All members of staff — “smart, intelligent women with a fabulous brain,” Periman said — are engaged in solving problems and making suggestions. Everyone is granted autonomy and empowered to use their unique personality and skills to contribute to the growth of the practice. They are also entitled to ask for whatever tool makes their job easier and better. Elevation entails providing opportunities for growth and celebrating successes.

“For example, our office manager doesn’t have a formal degree but has tremendous potential and is very hard working, smart and motivated. We worked together in various occasions in the past, and during the pandemic, she started off as my virtual office manager. Then, since we had enough positive cash flow, I brought her on full time with benefits and created for her a career growth trajectory to be our clinical research coordinator,” Periman said.

Another example was her licensed master esthetician. Periman realized she had outstanding teaching skills and is now working with her on the courses on dry eye.

“Having her as a resource inspired me to develop the educational side of my activity, and that will also provide a new revenue stream for her,” Periman said.

Finally, enthusiasm is the energy that makes everyone work toward a common goal and is nourished by acknowledging and celebrating individual accomplishments and common achievements.

“And also, the achievements of our patients,” Periman said.

The pond theory and cross-training

Healio/OSN Board Member Darrell E. White, MD, described the culture of his office as “a group of adults behaving like adults and treating each other like adults.” Unlike most practices in health care that are set up as a steep management pyramid, his clinic is built around the “pond theory of management.”

“If you look at our organization chart from the side, you don’t really see anything except one tiny little line sticking up, with a little flower on top. But if you look at it from the top, it’s as if you’re looking down on a frog pond, with lily pads flowing on the surface, one for each employee in the business. In many places, lily pads overlap, and these are tasks and responsibilities that can be shared among two or more workers. The people involved decide together who will be the lead person for that task and make sure that the lead person will be successful. There is no middle management, and the little flower is me, the one who sets all priorities,” White said.

This structure requires people who are able to interact with one another and do not need a referee to deal with interpersonal conflict. It also requires people who are willing to expand their skills and knowledge by cross-training. Employees were carefully selected based on this, and this shared mindset has made White’s practice capable of smoothly navigating the challenges of the pandemic.

“We didn’t lose anybody at all. Everybody was looking out for one another and filling in when somebody was in need. This was possible because we do intense cross-training. Everybody in our office is capable of being fully functional in one other very different area and then another area where they can be rapidly trained up to functionality,” White said.

White’s practice has only 25 employees, and he is not sure if this model could work for larger practices. Dunbar’s number could potentially be the limit.

“According to Dunbar’s theory, the human brain is capable of managing on a personal basis up to 150 direct relationships. Some companies, such as Gore-Tex, have actually utilized Dunbar’s number in their structure. When they have a working group that is getting bigger than 150, they not only start a new working group, but they build another building on the campus,” he said.

High-touch engagement

Remote monitoring in its earlier form, in pre-pandemic times, was unsatisfying, according to White.

“Patients were used to a very high-touch engagement in our office and did not like [remote monitoring] very much. We, doctors and optometrists, didn’t like it either because we felt we did not get adequate information from the patients,” he said.

However, in response to the pandemic, his group was led to set up a new monitoring model with true remote capabilities.

“Since I am the only surgeon in my group, that’s a really big deal. If one of the optometrists is seeing a patient and they have a problem, we can now do a real-time video slit lamp examination: I can see fundus photographs, I can see ORA, I can see visual fields, I can see topography because they come up instantly on our EMR. So, we became much more effective at remote visits, whether it’s the doctor who’s remote or the patient who’s remote,” he said.

In response to COVID, White was also motivated to adopt new technologies, such as the Ocular Response Analyzer (ORA, Reichert Technologies).

“I acquired that with the sole purpose of increasing the 10-inch space of traditional tonometry examination to 3 or 4 feet to reduce the risk of infection. And it turns out, it made us all better glaucoma doctors because we were getting more accurate IOP measurements, as well as additional information on corneal biomechanics,” he said.

White’s employees have not been working from home, and the issue was never raised in his practice.

“Our value proposition as a business is high touch. We like to interact all the time, and there is a lot of mutual support. We cooperate to meet each other’s needs, and this is helping a lot to meet the challenges of the pandemic,” he said.

He likes to compare the culture of his practice to that of a tight little village in which everybody knows everybody.

“We have created a kind of big comfort blanket around our staff. We cannot compete from a salary standpoint with the large academic organizations of our city, but the human aspect, the way we value each person and interact with one another, is what makes people come and stay,” he said.

It was often said that the pandemic would be a death knell for small traditional practices, but White does not agree.

“For many of us, it has been quite the opposite, and I know a lot of small practices that are thriving,” he said.

Shamie said that her decision to be a manager has been challenging but has added an extra flavor to the joy she takes from being a physician.

“It has allowed me to ascend. It has empowered me,” she said. “Now I think that in order to deliver the kind of medicine that I want to deliver, I also need to know how to manage my staff, how to fortify the foundation of the practice, so that it can outlast me.”

• References:
• Capitena Young CE, et al. Telemed J E Health. 2021;doi:10.1089/tmj.2020.0424.
• Kalra G, et al. Ophthalmol Ther. 2020;doi:10.1007/s40123-020-00269-3.
• Mercer GD, et al. Ophthalmic Epidemiol. 2021;doi:10.1080/09286586.2021.2008454.
• Porwal AC, et al. Indian J Ophthalmol. 2021;doi:10.4103/ijo.IJO_1592_21.
• Saleem SM, et al. Am J Ophthalmol. 2020;doi:10.1016/j.ajo.2020.04.029.
• Sanjay S, et al. Ophthalmic Epidemiol. 2021;doi:10.1080/09286586.2021.1934037.
• Tan TE, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2021.07.027.
• Tham YC, et al. Br J Ophthalmol. 2021;doi:10.1136/bjophthalmol-2020-317683.

• For more information:
• Lisa K. Feulner, MD, PhD, can be reached at Advanced Eye Care & Aesthetics, 104 Plumtree Road, Suite 107, Bel Air, MD 21015; email: lkf@advancedeyecaremd.com.
• Laura M. Periman, MD, can be reached at Periman Eye Institute, 320 W. Galer St., Suite 201, Seattle, WA 98119; email: dryeyemaster@gmail.com.
• Neda Shamie, MD, can be reached at Maloney-Shamie Vision Institute, 10921 Wilshire Blvd., Suite 900, Los Angeles, CA 90024; email: ns@maloneyshamie.com.
• Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.

Click here to read the Point/Counter to this Cover Story.