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When loyalty becomes a liability
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I was approached by an orthopedic client at a recent conference. Our firm had conducted a revenue cycle assessment for his solo practice. He told me we had issued a good report with lots of practical ideas for improvement. The problem was he couldn’t get the staff to implement any of them. They would not/could not/did not want to do anything differently and were unreceptive to his requests for new technologies and billing process changes. As the physician did not want to upset the staff, he didn’t push things, but he told me it was like being tethered to a ball and chain. Still, the staff wouldn’t budge. Ultimately, cash flow crumbled and managing the practice became too frustrating, so he took an employment offer from a large group and everyone in the practice lost their jobs.
Increasingly, we find ourselves coaching physicians to recognize staff are not shareholders in the business and do not get a vote on what is best for the business side of the practice. This orthopedic surgeon’s mistaken sense of loyalty to the staff resulted in all of them having to seek other jobs, which was not easy given their outdated skill sets. All of them had, in our assessment, below average reimbursement cycle and technology abilities.
Break out of the comfort zone
If you practice solo or in a small group, you probably employ staff who have been there a long time; so long, in fact, that some of your standard operating procedures, job descriptions and policies have been bent and warped to accommodate the staff’s personalities instead of what is right for the business. The result is a collection of people who have been given the luxury of doing things the way they want to for a long time and the consequence is institutional inertia.
When the external environment shifts, for example, to value-based care or the need to implement new payment and patient engagement technologies, these employees may feel it is not in their job description to change things. Their job has been custom-fit to support their schedule and skills and it provides a predictable, steady paycheck. These employees will not risk leaving their comfort zone and they develop an unwillingness to learn and change. If you have allowed people like this to work for you for years and maintained low expectations of them, admit you have enabled the problem, apologize, and get them the skills they need.
Physicians who enable mediocrity will face a difficult situation when big shifts occur in the external environment. Consider the increase in high-deductible health plans, which has created a need for practices to implement presurgical deposit and point-of-service collections. Those who have not made this shift are seeing skyrocketing accounts receivable in patient-owed balances over 90 days and 120 days. Recently, in a practice for which we recommended up-front collections to help improve this, the staff told me, “We don’t want to ask patients for money.” We explained that if they wanted a paycheck, they would have to do that.
It is famously said that actress Grace Kelly responded to director Alfred Hitchcock’s stage instruction when making one film by saying, “I don’t really want to do that,” to which Hitchcock replied, “Grace, I don’t care what you want to do. You just need to act like you want to. That’s your job.”
Physicians could take a lesson from Hitchcock’s response to Kelly. I’ve observed several practices that were kept from growing by the staff. Physicians usually know something needs to change, but if they get pushback from staff, they acquiesce.
All good things may come to an end
A few years ago, we recruited a woman to manage a client’s solo practice. She did a terrific job, until the practice grew. Her performance had been good when she could perform operational and practice tasks herself as the sole employee. She worked hard and put in long days. However, as the practice expanded, she needed to hire people to help her. The surgeon looked to this woman to take on the role of trainer, coach and supervisor. The problem was, she could not make the leap. She did not like sharing information, was highly critical of others and caused almost 100% turnover. Staff who were deemed competent and recognized as such by the physician were her first targets. Finally, the physician saw the pattern and had to let a person who had been a key employee during the early days of his practice leave.
The point is that sometimes a staffer who was your right-hand employee when you started in practice or a high performer when the practice was in a growth stage is not the staff person you need now. Perhaps they’ve lost their enthusiasm or let their skill set atrophy, or they like doing things the old way and refuse to adopt new technology.
It is painful to realize you have outgrown your staff, but it is a normal part of business growth. It does not mean you have failed the employee or the employee has failed you. It is just as important to embrace the beginning of an employee’s tenure as it is to recognize and celebrate the end.
Successful businesses are like human beings. They start as small children, move through an adolescent stage and eventually grow up to be adults. The key is to recognize that smart business decisions do not just benefit one person in the practice if four or five people are employed. These decisions should benefit everyone and be right for the entire business.
If these patterns sound familiar, there are steps you can take to ensure a less bumpy future. For one thing, realize you have set the example. No surgeon worth his or her salt is operating the same way he or she did when they completed fellowship. Surgeons are life-long learners. Here are three ways to cultivate the same attitude from the staff:
Foster professional development. It’s unrealistic to expect staff to see and embrace big-picture change if they haven’t been provided opportunities for training and growth. People will often resist change if they don’t feel they are smart enough to learn the new system or they feel their skills are outdated and they will be let go. As Benjamin Franklin said, “An investment in knowledge always pays the best dividends.” When employees gain knowledge, they feel competent and capable, which usually results in them being more participative in finding solutions to problems or changing initiatives.
In today’s fast evolving health care environment, training and professional development are expenses to over-invest in. Add these to your annual budget. For the best results, send a team of people to training to ensure new ideas will be adopted. Provide at least annual training to keep coders and billers current. The government doesn’t stand still. Training cannot be one and done.
Start an in-office journal club. Encourage employees to read trade journals, articles and e-newsletters, and attend webinars. Have a board where people post good ideas. When staff return from an educational program, ask them to present a 15-minute overview of what they learned, first to you and then during a staff meeting. Discuss the three most important takeaways for your practice, which helps everyone learn and grow.
Empower people. Invite staff to the table when changes are being planned. Don’t go off and do the planning in secret, leaving them to wonder what is happening or whether their jobs are at-risk. Empower staff to be part of the solution or change and they will be more engaged. When people feel they have choices, it reduces fears about loss of control, loss of their job and insecurity about their new role in the organization. Involving staff makes them feel they have a certain amount of control over their environment.
Assessing staff’s ongoing effectiveness and contribution to the practice calls for surgeon-level attention. Even if you employ an experienced practice executive or a highly effective office manager, no one has the same level of commitment to practice growth and performance that you have. You own the practice debts and all the potential profits. “This is the way I’ve always done it” is not a profitable mindset. Those who resist well-conceived change may need to move on. If you think of it as freeing them, like a bird trapped in a cage, instead of firing them, the process will go more smoothly.
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- Karen Zupko is the president of Chicago-based KarenZupko & Associates Inc., a consulting and education firm that has been advising physicians about the business side of medicine for more than 30 years. The company develops and delivers national coding and reimbursement workshops for the American Academy of Orthopaedic Surgeons. Learn more at karenzupko.com.
Disclosure: Zupko reports no relevant financial disclosures.