I don’t often find articles that reflect my own views as closely as the article “10 Ways to Keep Employees Happy” from HowStuffWorks by Cristen Conger does.  Not only does Ms. Conger hit the list with 10 strong concepts, but she also gives great sources to back up her points.  Here are her 10 points – click each one to go to the page for more information.

10. Offer Flexible Work Options Some jobs in medical practices are ideal for flexible work options, but most are not. Any position that requires face-time with the patient will likely need to adhere to appointment hours.  My question: is it “fair” to allow some positions to have flex-time and others not?  If you have a group of people all doing the same general job, letting some people have flex-time and others not may lead to a mutiny.  Consider carefully the precedent you are setting when allowing flex-time, and make sure employees understand that as the needs of the organization change, work arrangements may need to change.

9. Practice Open Communication I couldn’t agree with this one more.  Communicate, communicate, communicate.  One-on-one, in departments, in all-staff meetings, in all-organization meetings.  I typically send out an electronic newsletter every Friday (an idea from my mentor, Tom Girton) that announces/reminds people of events, clarifies policies and acknowledges achievements.  Oh, and don’t forget to make sure that people are understanding what you’re trying to communicate.  Touch base every once in awhile to make sure the message you’re sending is the one they’re receiving.

8. Pencil In Face Time When beginning a new job I often meet with every employee who reports to me (and sometimes meet with everyone in the organization in a smaller practice) for at least an hour to learn a bit about them and hear what they think the practice is doing well, and what the practice could be doing better.  Yes, it takes a lot of time, but it starts to form a bond with individuals and it gives me more information that anything else I could do to start to learn about my new group.  People are fascinating and I really enjoy an uninterrupted hour with someone – it’s almost a luxury in this day and age.  Once you’ve established that bond, make sure to nourish it by connecting with individuals on a regular basis.  Letting people know you truly care about them as individuals is how dynamite teams are created.  And the karma ain’t bad either.

7. Recognize Success and don’t save it all up!  Recognizing efforts, going the extra mile, dealing with a difficult patient, all deserve a pat on the back in front of other employees.  Remember to always praise in public and counsel in private.  Share the joy of something well done, and let the employee have the privacy of a critique.

6. Set Goals I like to establish individual goals every six months during the annual performance review and six months later during a less-formal touch base.  12 months is a long time to keep a goal in mind, so I prefer to deal with 6-month goals.  Performance evaluations should not be a rehash of what was done right and wrong over the year, but rather should be a time to review the goals from the last six months and see what wasn’t accomplished and why, as well as celebrating the goals that were accomplished. See my simple evaluation for more information.

5. Explain the Big Picture I’m often surprised how many medical practice employees don’t understand how their job (especially done well) contributes to the big picture.  Check-in staff might not understand how their job impacts billing.  Scheduling might not understand how their job impacts the nurses.  Nurses might not understand how their job impacts the check-out.  No one may understand what their efforts mean to the financial viability of the practice.  If all the staff know that they haven’t had raises for two years yet new medical equipment is being purchased for a new service line, they need to have some insight into why a decision was made and what potential it may have for keeping the practice viable.

4. Provide Career Growth Opportunities This fits in well with the 6-month performance evaluation when you set goals with your employees.  Goals may include projects, new skills, improved skills, shadowing other jobs, cross-training on other jobs, conferences and workshops, and online or classroom training.  Never think that someone can’t do something as predicting success is one of the hardest things in the world.  Encourage everyone!

3. Give Employees Respect Give everyone respect.  Know that every single person is much deeper than you will ever know and more fragile that you would ever expect.  Never forget that you can make someone’s day and break someone’s day.  Being a manager is making a choice to care for and respect the people who have chosen to work with you.  In many ways, management is the most powerless job (next to parenting) there is.

2. Provide Consistent Feedback For you to effectively provide feedback, positive or negative, the employee must have been trained, must have resources to help them do their job and must understand the expectations of the job.  Do not take for granted that your front desk person knows instinctively that your expectation is to have the day’s charges posted and reconciled before the end of the day.  Have written performance expectations for each person, then explore the reasons why those expectations are not being met (communication, misunderstanding, workload, etc.)

1. Build Trust I’m so glad Ms. Conger put this as #1 -I agree!  Here’s how I build trust: Keep confidences.  Follow the same rules I set for the staff (if they can’t eat at their desks, neither can I.)  Make promises sparingly and fulfill all promises.  Don’t mess up peoples’ payroll or their time off.  Understand the details of their job.  Don’t allow the doctors or the patients to abuse them.

What’s not on this list that you would add?

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Most of us have heard that interviewers make up their minds about applicants in the first minutes, or even seconds of an interview.  But what about once the applicant has been hired, or even once an employee has been with us for several years?  Do we base our beliefs on an employee’s ability to take on a new challenge or improve their performance on something real, or things we believe to be real?

New research shows that managers with a fixed view of people’s attributes tend to “ignore improvements or deterioration in the performance of their staff, and are also less likely to ensure they receive the training they need.”  The research findings, reported on the British Psychological Society Research Digest Blog, are as follows:

One study, for example, gave managers negative background information about a fictional employee before they were shown that same person performing well at a negotiation task. Managers with a fixed view of personal attributes (they tended to agree with statements like “As much as I hate to admit it, you can’t teach an old dog new tricks. People can’t change their deepest attributes”) subsequently rated the employee less positively than managers with a belief that people can change.

Another study found that managers who think people’s attributes are fixed gave their staff less coaching, presumably because they think such interventions will be ineffective.

The good news is that once managers become aware of these findings, they can change their minds about employees being able to change and improve!  Read the article here.

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Whether the title is manager, medical practice manager, physician practice manager, administrator, practice administrator, executive director, office manager, CEO, COO, director, division manager, department manager, or any combination thereof, with some exceptions, people who manage physician practices do some combination of the responsibilities listed here or manage people who do.

Human Resources: Hire, fire, counsel, discipline, evaluate, train, orient, coach, mentor and schedule staff. Shop, negotiate and administer benefits.
continue reading "What Does a Medical Practice Manager Do?"

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I am very pleased to have had the opportunity to interview Ester Horowitz, the founder and CEO of M2Power, Inc., and the voice of sanity among the current confusion surrounding the Red Flags Rules.

The Federal Trade Commission (FTC) states that the Red Flags Rule:

was developed pursuant to the Fair and Accurate Credit Transactions Act (FACTA) of 2003. Under the Rule, financial institutions and creditors with covered accounts must have identity theft prevention programs to identify, detect, and respond to patterns, practices, or specific activities that could indicate identity theft.  The Rule applies to creditors and financial institutions.

Most medical practices have been identified as creditors under the Red Flags Rule.   The FTC defines a health provider as a creditor if they “bill consumers after their services are completed.  Health care providers that accept insurance are considered creditors if the consumer ultimately is responsible for the medical fees.”  Note that being a creditor is not linked to whether you take credit cards or not.

Creditors then must determine if they have “covered accounts.”  The FTC states that “A covered account is used mostly for personal, family, or household purposes that involves multiple payments or transactions.  This includes continuing relationships with consumers for the provision of medical services.”

Horowitz has written an excellent article on the Red Flags Rule and is receiving calls weekly from medical practices asking her for guidance.  She notes that many practices are having trouble distinguishing between the new Red Flags Rule and the existing HIPAA standards, and practices may think that compliance with HIPAA meets the criteria for the Red Flags Rule.  Horowitz says emphatically, “There is a distinct difference between PHI (Protected Health Information) and what the Red Flags Rule considers “identity” information.”  Although there may be some overlap in HIPAA and the Red Flags Rule, existing HIPAA programs will not be sufficient to keep a practice from incurring fines, if identity theft is traced to the medical practice.

Horowitz outlines the fines as follows:

Employee or Customer information lost under the wrong set of circumstances may cost a company or practice:

• Federal and State Fines of $2500 per occurrence
• Civil Liability of $1000 per occurrence
• Class action Lawsuits with no statutory limitation
• Responsible for actual losses of Individual ($92,893 Avg.)

Note the word “employee” in the paragraph above.  The medical practice is responsible for the information contained in “employee applications, payroll data, W-2, social security numbers, drivers licenses, and credit cards, military records, and birth certificates” as well as information derived from consumers.

What are the requirements of the Red Flags Rule?  A creditor with covered accounts must:

1. Develop a written program, approved by its board of directors, that identifies warning signs and suspicious activity of possible identity theft.
2. Develop measures to prevent identity theft must be implemented.
3. Mitigate damages from instances of identity theft.
4. Ensure that staff is be trained/retrained periodically.

How does one detect identity theft?  It is rarely easy, therefore one typically only finds out after the fact.  For medical practices, asking for picture ID each and every time the patient is seen might be the only way to determine identity.  It would make excellent sense for insurance cards to have photos on them, however, we are all changing insurance policies so often now that this does not seem feasible.  Some practices routinely copy the new patient’s driver’s license.  Others take photos of the patient and store them in the paper record or digitally in the EMR.

Horowitz points out that fake IDs are quite common, as your teenagers could probably tell you.  With the number of people losing insurance coverage when they lose their jobs, can we expect in new black market in fake insurance cards?

The other problem that Horowitz describes is that of mixing care for two different people, one the actual person and the second the identity thief.  She notes that practices have a “medical responsibility to find and treat the right person.”

I asked Horowitz about the issue of using the social security number as a patient identifier in medical practices.  Many practices require the pateint’s social security number, as it still is the single most useful number for matching patient identities and for collection purposes.  She said “Use of the social security number in healthcare is not going away any time soon.  Remember that Medicare cards still use the social as its basis.  Practices must do everything in their power to limit the exposure to that number and to protect it.”

Horowitz also noted that every system devised will have its thieves – something like “build it and they will break it.”  She feels that the critical piece is to have monitoring systems in place to be alerted to the first signs of identity theft so that the ramifications can be minimized.  She suggests that practices educate their employees as to the devastating (financial and emotional) effects of identity theft, and encourage personal monitoring programs.  Whether a practice decides to provide these programs as an employee benefit is a decision each will have to make.  Providing coverage for employees would certainly be a strong indicator of proactive intent to protect the employee if an employee’s identity was stolen from information housed with the employer.  Horowitz also recommends that practice provide patients with literature about identity theft (not required by the Red Flags Rule), and especially let the patients know if any process in the practice will be changing (e.g. showing a photo ID at every visit.)

As for the new compliance programs for Red Flags, Horowitz can provide a customized  program, employee education, and a monitoring model so the practice is ready for the May 1, 2009 deadline for having the program in place.  The deadline is less than 55 days away – do you have your program in place?

More about Ester Horowitz:

Ester Horowitz is founder of M2 Power Inc, and serves as practice marketing and business advisor for the medical industry working with doctors, chiropractors, LCSWs and other health professionals.  She helps implement marketing & business actions plans within the professional codes of ethics, HIPAA, and fraud and abuse compliance obligations.  Her nationally acclaimed publications focus on the business of medicine and include such articles as “The Death of Dr. CEO”, “How to Find $50,000 in Your Practice”, “What Does Buying, Selling, and Growing a Practice Have in Common”, “When Selling a Practice What is Important to Know”, a video – “Raising Capital”, and her book The Blatant Truth of Owning a Medical Practice: Rx for Practice Owners.  She can be contacted via her website.

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James Smith, MBA

Note from Mary Pat: Please welcome my guest columnist Jim Smith, MBA who has written on the subject of change.  His original article was written about the Washington State Department of Transportation, but he has been kind enough to let me change WSDOT to ABC Medical Practice, a very large and fictitious medical practice that resembles almost every practice you and I know.

Over the past twenty years many changes have been made at the ABC Medical Practice. Almost always they were changes which improved employee production and modified the then current way of doing things. I have noticed the staff employed at the practice are only interested in doing things the “way we have always done it.”  My point is this; people are not creatures of change, do not like change, will not suggest change, and when confronted with change quite often reject change.

Reinventing healthcare and group medical practice is a mammoth task, much larger than any change efforts at a big corporation. The ABC Medical Practice has many employees and dozens of departments. How do you begin to change something so large and bureaucratic?

To begin with, you have to recognize that you’re dealing not with one large organization but with lots and lots of individual bureaucracies, each of which has its own concerns and needs. Each unit must move through the change process in its own particular way. Every department is going to have to approach change on several different levels. The first step in any change—and it doesn’t matter if you’re running a division of GM or Kiser Permanente —is to begin to ask the basic questions: What business are we in? What’s our mission? Who are the customers we’re aiming to serve? You must answer those questions carefully.

Then, if you’re truly going to understand the most important problems and begin to look for answers, the second step is to draw on the experience of people from all organizational levels. How do the services you provide look to employees in the field? How does it feel to be a customer of your company?

In healthcare, the answers aren’t necessarily the same as those in business.  Who are the customers of the ABC Medical Practice?  Patients?  Referrers?  Payers?  The federal government?  The state government?  The owners?  Those questions—and their answers—are important, but they aren’t obvious. After you have defined your mission and your customers and then learned what those customers want, you need to articulate a vision of change and sell that vision to every employee.

Look at change from four thematic perspectives: customers, consequences, control, and culture. First, you need to revamp the relationship between your organization and its customers. You have to ask customers what they want and then restructure your organization to deliver it. Second, you need to create consequences for what people and organizations do. In business, if employees can’t deliver what they were hired to deliver, they leave or are fired. If the business can’t make money and keep customers happy, it doesn’t survive.  Somehow, managers have to create a feeling that what people do day-to-day to advance the mission of their practice really is important. And healthcare leaders have to create performance measures, budgets and other systems that reward success and force weak performers to improve.  Healthcare workers are no different than other employees; they want to see their efforts matter and their progress measured.

Third, you need to look at who has control. In healthcare, control is vested at the top much more than in almost any business. If you want an organization to become more entrepreneurial and alert to customers, you must give a lot more control to the people on the front lines who deal with customers and deliver the services. That’s as true of healthcare as it is of business.

Finally, you need to ensure that the culture of the medical practice supports the work that people need to do to deliver value to the customer. In the workplace, long-standing cultures have taught people to keep their heads down, stay out of trouble, and, unfortunately, they have accomplished little. The key is to craft a different kind of culture.

Conversations about the vision of the future and your mission have to start at the very top. The doctors have to get out there and talk about that vision again and again. The leaders must do the same, but they need to be more detailed-oriented and talk about specific goals. And so on down to every level.

A crisis helps enormously. Companies like Harley-Davidson and Ford have used crises in a similar manner. If you don’t have an obvious crisis, sometimes you have to try to manufacture one or at least create an overwhelming sense of urgency. You can say, “This is the level of performance we need to attain, and we’re doing a miserable job.” You can talk in quantitative terms about where you are and where you want to be and involve everybody in choosing the strategies to get there. And then, when you reach the point where you hit your goals, you shouldn’t be shy about trumpeting it. Successful results can protect you from the internal and external opposition you’re almost certain to run into.

Until now, change in healthcare has been an either-or proposition: either quickly create economic value for owners or patiently develop an open, trusting corporate culture long term. But new research indicates that combining these “hard” and “soft” approaches can radically transform the way businesses change.

The new economy has ushered in great business opportunities—and great turmoil. Not since the Industrial Revolution have the stakes of dealing with change been so high. Most traditional organizations have accepted, in theory at least, that they must either change or die. And even Internet companies such as eBay, Amazon.com, and America Online recognize that they need to manage the changes associated with rapid entrepreneurial growth. Despite some individual successes, however, change remains difficult to pull off, and few companies manage the process as well as they would like. Most of their initiatives installing new technology, downsizing, restructuring, or trying to change corporate culture has had low success rates. The brutal fact is that about 70% of all change initiatives fail.

In our experience, the reason for most of those failures is that in their rush to change their organizations, managers end up immersing themselves in an alphabet soup of initiatives. They lose focus and become mesmerized by all the advice available in print and on-line about why companies should change, what they should try to accomplish, and how they should do it. This proliferation of recommendations often leads to muddle when change is attempted. The result is that most change efforts exert a heavy toll, both human and economic. To improve the odds of success, and to reduce the human carnage, it is imperative that executives understand the nature and process of corporate change much better. But even that is not enough. Leaders need to crack the code of change.

To Recap:

• Each medical organization is made up of official and unofficial departments and each department will have its individual perspective, needs and culture.Who is your customer? (Examine this carefully – you might be surprised.)
• Are there any consequences for not being willing to change? Is the culture really going to change, or is it just a lot of talk?
• Are those in control the ones talking about the vision?  If the doctors own the practice and they don’t truly believe in the change, neither will the staff.
• Is there a crisis?  If you are in healthcare, whether you believe it or not, there is a crisis.
• Don’t overwhelm the practice with initiatives, unless they are important and not just the flavor-of-the-month.
• Celebrate successes!

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Am I the Commissioner of Baseball?

Most people who ask what I do have never heard of managing medical practices.  Many people say “I didn’t know there was a job like that.”  Medical Group Management Association’s (MGMA) definition of medical group practice and medical practice management is helpful:

Medical group practice is defined as three or more physicians engaged in the practice of medicine as a legal entity sharing business management, facilities, records and personnel. This includes single- and multispecialty physician offices, ambulatory surgery and diagnostic imaging centers, hospital-based practices and academic practices. (Medical Practice Managers) … are part of a large and growing field that requires broad knowledge, skills and experience for long-term success. And the decisions they make directly affect nearly every aspect of a practice’s operations, from financial performance to patient care.

The next question many people ask is “How do you learn to do that?”  People who do what I do come from lots of different professional backgrounds.

It has been a fairly recent development that there are undergraduate and graduate programs for this field.  Many physicians who are business-minded have pursued degrees that allow them to manage their own practices while practicing medicine, or enter the healthcare management field and leave active clinical practice.  According to a recent Times article, there are 49 schools that currently offer a dual MD/MBA degree.

Here a few ways other than formal healthcare management training that medical managers enter the field.

Nursing/Clinical: I have known some excellent medical practice managers who have four-year nursing degrees, but I don’t know a lot of them.  It seems that most nurses want to be nursing, not managing, and that they became nurses to care for patients in a hands-on way.  I have observed that some managers with nursing backgrounds are instant fixers, and have trouble taking the contemplative route to problem-solving.

Management Experience: There is no question that private practices are coming late to the business party and that experienced managers bring a lot to the field.  It can be hard, however, to jump into managing a practice with no former healthcare experience because so much is so different.  The owners of the business (the docs) are also the ones producing the revenue.  As my husband says, the job is very much like being the Commissioner of Baseball.

MBAs: Having a MBA brings a lot of tools and resources to the table, but is not the be-all and end-all, especially when it comes to people-management.  The best managers in any field truly like and value people, have time for people, are collaborative with people, and care about people.  Can this be learned?  I don’t know.  Probably not genuinely.

Technology: Managers who understand and embrace technology will have the advantage over every other manager.  Healthcare and technology are becoming more and more wedded.  Every priority technology function that healthcare managers have to outsource is an aspect of the practice that is somewhat out of their control.  Think practice management systems, EMR, phones, PACS, email, knowledge management, lab interface, hospital interface, patient communication, etc.

Up through the ranks: Managers who have come up through the ranks have a big plus in their favor and a big minus.  The plus is that they understand healthcare, the nitty-gritty functions of the practice, have experience relating to administrative and clinical staff, and know how to network.  The minus is that they are usually undervalued due to the lack of formal education, and may also undervalue themselves for the same reason.

In the end, it’s not where a person comes from that makes the biggest difference, it’s who they are and what they’ve made of their career.  Anyone can enter the field of healthcare management, but I do suggest  these three prerequisites:

1. Compassion for patients (compassion for all people)
2. A desire to continuously learn; if you stand still you’ll get moldy
3. A sense of humor.

Here’s an interesting history of the field of medical practice management.

Photo credit: Mary Pat Whaley

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What have you done for your career lately?  Are you comfortable in your current job?  Are you happy?  Happy with your income?  Happy with your level of challenge?  What would you do if you lost your job tomorrow?

Do yourself a favor and invest a little time in your future.

At WordCamp recently, Lorelle VonFossen said “You need to think about having a digital presence.”

I suggest that signing up with LinkedIn (free) and building your online presence is a good start.  LinkedIn could be called the business version of FaceBook although many people use FaceBook as their business networking tool.  The general consensus is that for business LinkedIn is probably the most-used (25 million people) and best-known of the social networking websites.  Social networking uses the theory that we’re all connected to each other through those we know and that every other person on the Earth is connected by six other people, thus the term you’ve heard “six degrees of separation.”  You use these connections to network and meet people, ask and answer questions, and possibly, find jobs.

There’s a lot to completing your LinkedIn online profile, but you don’t have to do at all at one time.  I think my LinkedIn profile is about 75% complete and I’ve been working on it for a couple of months.  Take your time, do it right, then start to look into joining some LinkedIn groups to see what people are talking about.  The trick is not to get hundreds of people in your network (unless you’re a recruiter), but to build authentic relationships with people you think well of.

If you’re not sure what social networking can do for you, check out these articles:

Jobseekers are Beginning to Favor Social Networking Over Online Career Sites to Find Jobs

The Social Network as a Career Safety Net

LinkedIn: Old-School Network Isn’t Short of Fans

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It seems that my most popular post to date has been the one I wrote on the difference between its and it’s.  This tells me that managers are looking for ways to improve their writing and communication skills.  Not being one to overlook the obvious, I thought I would write a post about the difference between your and you’re.

I’ve been reading blogs and blog comments so much lately that my eyes are almost crossed, but one thing that does jump out at me is the tendency for many writers to confuse the two words your and you’re.

Remember the rule for its and it’s?  This one is almost the same.

If you can substitute the words “you are” in the sentence, use the apostrophe.  For example, “You’re reading my blog” can also be expressed as “You are reading my blog.”

If the words “you are” make no sense whatsoever as a substitution, do not use the apostrophe.  For example, “You’re blog is fascinating,” sounds fine, but makes no sense when you substitute it with  “You are blog is fascinating.”  This is the place to use “your”, as in “Your blog is fascinating.”

Your choice of words makes all the difference, and you’re the one to make that choice.

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A great column in last week’s BusinessWeek by Carmine Gallo gives the reader 4 steps to making difficult conversations with employees and coworkers more productive. I like his steps, but I have four of my own, and I’ll let you choose which works for you. Read Carmine’s suggestions here.

Here are my four steps:

Step 1. Always start with a question. I rarely feel that I know the complete story so I typically ask for more information about the issue or behavior in question. Nine times out of ten I learn something I didn’t know that helps the conversation. Asking questions and clarifying information usually gets both parties a little more comfortable.

Step 2. Express your concern about the issue or behavior and let the employee know why you’re concerned. More information helps the employee see how their work interacts with someone else’s or contributes to the organization as a whole.

Step 3. Ask for the employee’s input in solving the issue or behavior. There may be several solutions that would work, and choosing the best one together, or letting the employee choose one is a win/win.

Step 4. Restate the action plan for the resolution and close the meeting with an invitation for either of you to meet again if the issue needs revisiting.

It may be hard to talk to employees and coworkers about issues or behaviors, but if you are in a leadership position, you must learn how to have hard conversations of all types. The secret is asking questions and collaborating on solutions.

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