by
John V. Guiliana, DPM, MS
Fellow and Trustee, AAPPM 

Unleash Your Staff’s Potential … Avoid Micromanagement

“The most effective executive is one who hires good people and then has the good sense to stand back and watch them do their work”. 

Many owners of small businesses often fall into the trap of micromanaging their employees.  Since most of these owners were, at one time, the ONLY employee of the business, they have usually performed every job within the business and know exactly what needs to be done and how to do it.  It is easy to understand (yet not to accept) the criticism that micro-managers often deliver to their employees in response to doing something in a slightly different manner.  After all, their way has worked since the “beginning of time”.…why should they let someone try something new?
 
Physicians, like other business owners, often micromanage their staff.  If you find yourself frequently suffering from any of the following symptoms, you may be a micro-manager:

* You often look over your employees’ shoulders and offer “advice”.
* You often listen to your employees discuss a problem and feel compelled to voice an opinion or suggest a solution.
* You often succumb to the urge to finish a task that was started by an employee.
* You often delegate some tasks within the project but never the whole project.
* Your employees relate that they feel unfulfilled in their job.
* Your practice suffers from a high employee turn over rate.

If you are the unfortunate “victim” of a micromanager, these symptoms are unmistakable.  Perhaps it is not only the doctor’s act of interfering that concerns you, but the inevitable criticism that micromanagement often leads to. 

Micromanagement is certainly not taught within the core curriculum of any business schools.  Practicing it will ultimately limit the growth of any business.  Particularly true in the challenging environment of medicine, constant innovation, thoughts, and ideas must infuse your practice in order to thrive.  These can only come from people.  These critical innovations, thoughts and ideas will only be extracted from people who feel “empowered”.

Empowerment may be considered the polar opposite of micromanagement.  It involves choosing your employees well, considering who is best for each task, setting goals and objectives and finally, giving them each the authority and the responsibility to make their own decisions that effect their work.  Eventually, this will not only translate into complete employee fulfillment, but you may soon find yourself surrounded by a team of creative self-thinkers who have the means of creating unlimited business growth.  Watch their full potential come alive!

As the leader of the team, you have the responsibility of providing feedback along the way so that the employee has the opportunity to change course or fine-tune their strategies.  Feedback is NOT the same as criticism however.  Feedback is merely dynamic, up-to-date insight on how close they are to the mutually agreed upon goals and objectives.  Positive reinforcement is a key ingredient of feedback.

So your boss is a micromanager…

If you find yourself under the wrath of a micromanager, consider your options.  The easiest (but perhaps not the most practical) thing to do is to quit.  I would certainly never recommend quitting anything as a first-line option.  The second easiest thing to do (although not very easy) is to simply change your response to micromanagement.  Recognize and understand your boss’s reason for micromanaging and separate out the good constructive feedback from the unrealistic criticism.  Unfortunately, as your valuable input diminishes in response to your normal defense mechanisms, you may eventually feel a great deal of apathy toward the practice.   Finally, the last option (and perhaps the most difficult) is to actually change your boss.  This option, while difficult, is the only one with real, long- standing potential.  It is the only option in which the practice itself will benefit.

Changing the behavior of another individual is a slow and tedious process.  Like all creatures, (I don’t recommend calling your boss a creature to his or her face), we gravitate to that which makes us feel good.  With that in mind, you need to give your boss the same positive reinforcement that he or she is giving you during this change of habit (changing from micromanaging you to empowering you).  Acknowledge any acts of empowerment that comes your way.  Make your boss feel good about it.  Slowly, you will see that behavior “stick”.    

Unfortunately, you will not change the behavior of your boss by simply providing him or her with information about empowerment, its rationale, scientific evidence of its effectiveness, or even this article.  You must make them want to change through slow and steady positive reinforcement...make them feel good about it!   An old but true proverb states “change a man against his will, he’s of the same opinion still”.

FootZine Volume 39

Putting out the Fires of Managed Care….Conflict Resolution Skills

In this rapidly changing medical financing system, one skill, which runs closely behind the doctor’s actual medical skills in the ranking of importance, is the skill of conflict resolution. 

Conflicts arise in many situations and take on many disguises. As an example, in the private practice setting, conflicts may arise if a patient shows up unexpectedly without an appointment or referral, if they show up early or late, if the doctor is running behind, or if they disagree or are confused over their bill.  The conflict may be manifested by the emotions of anger, frustration, rudeness, or in some instances, simply silence.

Unresolved conflicts usually end in disputes, with the most devastating outcome being that of litigation.  Long before a dispute may arise, however, a conflict will result in loss of goodwill, loss of the customer (and their potential referrals) and lost revenues.

The “art” of conflict resolution DOES NOT mean relinquishing your position and “giving in”. Actually, it’s just the opposite. Conflict resolution involves a positive outcome. It will usually result in people crossing over to “your side”.

Let’s start by reviewing a typical response to a conflict. As humans, we have a strong desire to express our point of view. This usually involves lots of talking (sometimes very loud talking). We have a “position” and we want it heard. The other party, however, also has a perspective and wants to be heard. They want their position acknowledged. This usually results in what is known as a “positional based” dialog. Positional based dialog strives for “one winner” and “one loser”. It’s a win-lose technique.

If we realize that all humans have a desire to maintain and express their interests, we must start by examining what these interests are and UTILIZE THEM TO RESOLVE THE CONFLICT.  Let’s break down the possible interests for each party in a typical conflict. You may THINK that a patient’s primary concern and interest in a conflict over a bill is to SIMPLY NOT PAY THE BILL. While this may indeed be the case in some rare instances, I assure you that this is not the majority of the cases. This is what the interests may look like:

Patient’s interest:

1.  Being heard…Made to feel that their interests are also important
2.   Venting their frustrations. Their frustrations may be as a result of this particular crisis, or may have nothing to do with it. The frustration may be a secondary emotion to confusion or perhaps the feeling of losing control.
3.  Lastly, NOT paying the bill.

Our interests:

1.  To GET PAID with as little hassle as possible

Again, in rare instances, the patient may have no other interests other than avoiding the payment. I’m certain that most Psychologists would agree, however, that in this type of conflict people generally have other “primary interests”.

The key to conflict resolution is to negotiate utilizing an “interest-based” system rather than a “positional-based”. Interest-based negotiation involves a “win-win” phenomenon. The interests of BOTH parties are addressed.

RESOLVING CONFLICT UTILIZING INTEREST-BASED NEGOTIATION  

If we are truly committed to resolving a conflict, we must start by identifying the interests of the OTHER party. How do you accomplish this?

Through what is known as empathic listening you can begin to identify the patient’s needs. This involves intense listening (not talking) and trying to “feel” what the other person feels like. With this type of listening (also known as active listening), emotions such as frustration, anger, fear of loss of control, etc. can be identified. These emotions must then be acknowledged.

A person’s feelings are acknowledged when you are able to accurately paraphrase them back to them. As an example, a paraphrase to a person whom you have identified as frustrated might be  “I know how frustrated this makes you feel; it drives me crazy as well when an insurance company doesn’t pay my doctors.” This paraphrasing opens the gates of communication since the patient now feels that they have been acknowledged and you UNDERSTAND.

Allow them to vent all frustrations. The “listening to talking ratio” should be about 10:1.

Only after opening of these gates of communication should you proceed to “tell your side of the story”. Choose your words carefully. Continue to speak in an empathetic tone and periodically interject those same emotions (frustration). DO NOT patronize.

If the patient hasn’t yet crossed over to your side, you may want to ask what we can do to resolve this conflict. Again, listen…don’t talk. If the results are not realistic, again state your case and explain why this is not realistic.

In those rare instances in which a person’s main interest is to simply not pay the bill, it is time to terminate the conversation. Ask the person if you can get back to them at a mutually convenient time to discuss this further. Disclose that you need to review this case further (with your supervisor, for example). The reason for this termination at this point is two-fold. It will allow some time for things to “sink in” for both parties. It will also give you some time to evaluate the potential decision from an “analytical” standpoint. You must explore the financial impact of trying to collect an $8.00 co-pay from a loyal, high referring patient and the risk of losing the patient as a result of this collection.  The classic “risk/benefit ratio” must be analyzed.  Perhaps not a popular view, but that ratio changes with each person. As a person, EVERYONE is valuable. But as a CUSTOMER, some are more valuable than others. There are times in which relationships need to be terminated for the benefit of both parties.    

The next time that you find yourself in a conflict, remind yourself of these skills. Are you listening and trying to establish an understanding of the other party? Can you make them feel as though you have addressed their interests? When it’s time for you to discuss your side of the story, are you continuing your empathetic tone?  Lastly, know the economic outcomes of all of your potential decisions.
FootZine Volume 36

Recently, a subscriber of FootZine questioned how to go about determining if another billing employee would benefit the practice. The "art" of making sound business decision such as this lies within the realm of "scientific management".  We can no longer simply rely on gut feelings.  We need to use the power of information to help increase the chances of a correct decision. The information required to make this decision, along with its potential impact, would be as follows:


1. How many patients/week does the practice processes?  A healthy podiatric practice performing in-house billing should have about three full time equivalent (FTE) employees per DPM.  FTE is calculated by taking total employee payroll hours and dividing by 40. 

2. What is the payor mix of the practice (managed care/ Medicare/ PPOs?)- this impacts the level of difficulty in the collection process

3. What does the practice's current A/R distribution look like?  i.e., what percentage of the A/R fall into the 30 day range, what percentage is in the 60, 90, 120)?  This provides information about the efficiency of the collection process.  "Current" should occupy greater than 60% of the A/R while the 120 day profile should be less than 20%. 

4. What is the practice's monthly billing as compared to the total accounts receivable?  Total A/R should never be more than 3 months billing.

5. What is the practice's payroll expense as a percentage of total receipts?  Around 20% is ideal.  Much greater and we have overstaffing and inefficiency possibilities.  Significantly less jeopardizes efficiency, quality and cash flow.

6. How often are invoices sent out on patient balances?  This should be monthly.

7. Do they currently use electronic claims submissions? 

8. Does the staff work overtime to achieve the current level of collections?  Routinely paying time and a half for staff overtime is usually an economic indicator that additional personnel is required.  Hiring may actually save money as well as preclude the devastation of staff burnout.

With this information, a practice can benchmark itself and increase the chances of making a sound decision regarding hiring additional personnel.  Information such as this is available through the American Academy of Podiatric Practice Management. 

FootZine  Volume 21

"I would like some advice.  I am trying to make the Doctor in my office work more than half days in order to make money.  He is basically a new doctor and he thinks that working half days he is going to do well.  In order for the practice to succeed we need a full time doctor in case a new patient walks into the office.  A new patient is a source of future referrals.  Please help me with ideas how to tell him and make him understand?  Or maybe I am wrong?"

I would recommend that you first establish your doctor's priority. Perhaps your priority of making money is not shared by him/her. If free time is not the priority, and building a profitable, secure practice is, then your frustrations are well founded.

I would start by demonstrating (in a concrete manner) what the loss is for working only half days. In the "growth phase" of a practice, seeing and accommodating patients in half the day is acceptable ONLY if the other half of the day is spent in a productive, practice-building mode. As an example, a new practitioner would be extremely productive seeing patients on a particular morning or afternoon, and visiting PCPs the rest of the day.  

If this is not happening, then some concrete evidence of the loss may help. Start by quantifying how many calls come in during "off hours" (by virtue of either your answering service or an answering machine).  In a typical podiatric practice, an estimated 40% of new patient calls desire to come in that day. If you miss 5 new patient calls , 2 of them would have come in during this "off time". By simple analysis, if you are not able to commit all five calls to an appointment once you are back in the office, you can assume that you have lost that 40% to a competitor.

Now for the concrete part...convert that lost fraction to a dollar amount each week. I estimate that each average new patient has a "value" of somewhere around $1500-$2500 (these numbers include all services as well as future referrals).  By presenting it in this manner, your doctor may soon realize that the expense of not being open far exceeds that of adding hours!

Good luck.

FootZine Volume 22

Managing The Job Interview

Some managers experience a mental block when interviewing a job candidate.  A checklist of questions makes it easier to provide revealing answers.  According to many sources, some of the most important skill sets required by employers in the coming years are:

* Understanding the necessity of taking direction
* The ability to work with others
* Speed and mental processing
* Analytical skills

The following questions serve to outline these areas for a Podiatry job candidate:
* How do you determine your priorities?
* How do you plan your week?
* How do you plan your day?
* What special characteristics should I consider about you?
* Why are you interviewing with us?
* What have you done that shows initiative and willingness to work?
* If you were hiring for this position, what would you be looking for?
* What was the previous job's biggest challenge?
* How many levels of management did you interact with?
* What kind of work interests you most?
* How would you describe the ideal job for you?
* What happens when two priorities compete for your time?
* What's the toughest communication problem you faced?
* When have your verbal communications been important enough to follow up in writing?
* Tell me about the time when someone has lost his/her temper at you in a business environment.
* Have you ever worked in a place where it seemed to be just one crisis after another?
* How did you handle it? How did you feel?
* What do you see as some of your most pressing developmental needs?
* Define cooperation.
* What quality should a successful manager possess?
* How have past managers gotten the best out of you?
* A two-part question: Describe the best manager you've ever had. Describe the toughest manager you've ever had.
* And last, for what have you been most frequently criticized?

I also like an idea of asking questions in the form “role playing” such as “what would you do if a patient did the following…”?

Some questions are, of course, strictly forbidden.  Various federal, state, and local laws regulate the questions a prospective employer can ask.  An employer's questions, either on the job application, in the interview, or during the testing process, must be related to the job for which the candidate is applying.  For the employer, the focus must be: "What do I need to know to decide whether or not this person can perform the functions of this job?" You can, however, obtain excellent data on people regarding those areas by asking the question in a slightly different fashion:
                
  Illegal                                                   
* Are you a US citizen?                        
* How old are you?                                
* What is your marital status?                                       
* Do you have children?                          
* Do you plan on having children? 
* Do you have any disabilities?               

  Legal
* Are you authorized to work in the U.S.?  
* Are you over the age of 18?
* Will you be able to work overtime or travel when the job requires it?
* Are you capable of performing the physical aspects of the job?    

Allowing the candidate to speak freely is your best source of information.  While we all love to speak, a job interview is a time to listen.  

FootZine Volume 26

John V. Guiliana, DPM, MS
Fellow and Trustee, AAPPM