Management: When It’s Time to Change

Mickey Mouse knows a thing or two about running a business. After all, the immense media empire inspired by the cartoon rodent must be doing something right. So goes the thinking behind the Disney Institute, an Orlando-based professional development center that aims to meet the business needs of individuals across all professions.

When Kimberly Wishon-Powell, director of consultative and support services at the large, multispecialty Holston Medical Group in Bristol, Tenn., was tasked with enhancing patient satisfaction by changing staff attitudes at an OB/GYN practice, she brought back to the office the lessons she learned at the Disney Institute.

“I basically gave employees parameters of what was expected of them in order to communicate with customer/patients,” says Wishon-Powell. “They were simple things, like, ‘You will thank everyone when [they] leave.’ ‘You will greet everyone with a smile.’” Wishon-Powell got a lot of pushback. Given that their’s was the busiest OB/GYN practice in town, the staff resented being taught what they perceived as “silly things.” After all, why should they change when they were already doing so well?

Sound familiar? It’s a common challenge in every business - affecting positive change despite resistant staff who’ve grown comfortable with “the old way.” But Wishon-Powell won them over, in time. You can do the same with yours.

The key to Wishon-Powell’s success in managing change was simply doing what her Disney teachers taught her. She explained to the staff that these “silly things” were essential to helping their employer continue growing by providing service excellence. Soon the staff saw themselves as vital contributors toward a common goal. Wishon-Powell coached them along, providing small incentives for established benchmarks, and soon the group buy-in she sought drove patient satisfaction off the charts.

Whether you are teaching your staff to say “please” and “thank you” or overhauling your entire practice management system, Wishon-Powell says the key to implementing change in any business environment is communication. And that communication must come from the top.

Whether they do so consciously or not, the staff put physicians on metaphorical pedestals, says Wishon-Powell, also the author of “Intrinsic vs. Extrinsic Motivation: How Much Does Money Really Matter?” So when a practice initiates a change of any kind, it must have the backing of the group’s top brass. “And that doesn’t mean making pronouncements via e-mail,” says Wishon-Powell. “Doctors really need to be involved with their staff in person-to-person communication.”

“The worst thing physicians can do during a major change in an office - or even a minor change - is to act like it’s not happening,” says Wishon-Powell. To further dampen staff attitudes, physicians can have a negative attitude about the change. If staff hear their supervisors complaining about a new procedure or product they are expected to learn, “you can make sure they are going to follow suit and resist it too,” she says.

Ask for input

“The only constant is change” may be a cliché, but it’s also a truism. For any business to succeed, it must constantly work to achieve ever-increasing levels of customer satisfaction as the marketplace vies for consumer dollars. Healthcare is no different.

But staff resistance to change - particularly within the healthcare delivery arena, which notoriously lags behind its business counterparts in keeping up with evolving technologies and customer service trends - is also a truism. It’s human nature to want to stay within the confines of one’s comfort level, especially in the workplace.

So what do you do? Empower your staff to be the change agents - even if they’re not. “Staff need to think they have a part in change, even if they don’t,” says Wishon-Powell. “To buy into change, staff must have a sense that they are part of it.” So they need to be involved from the start.

“Communication is your best weapon for any kind of change process,” says Becky Kronauge, practice administrator for Acute Care Consultants in Dayton, Ohio, and PAHCOM’s (Professional Association of Health Care Office Management) 2007 Medical Manager of the Year. Change affects different people different ways, she says, and resistance to change is often the result of physicians or middle management not asking for staff input, not conveying vital information, and - most important - not allowing their employees to verbalize their concerns.

“You want them to be able to say, ‘I don’t agree with this or feel comfortable doing that,’ and we do want people to provide us feedback,” says Kronauge. “Sometimes we make changes whose impact we don’t realize … So we try to be open when we’re making changes to include people in the process along the way, not always being top-down, the management telling everybody what to do.”

You’re wearing that?

That includes telling people what to wear. An office’s dress code is likely not at the top of a busy physician’s list of concerns. But staff may very well perceive hastily written memos regarding new office dress rules as arbitrary edicts or even personal attacks on a specific employee’s mode of self-expression.

Nancy Becker, a practice management consultant in Westchester, Pa., relays one memorable experience she had in which she walked into a practice and was greeted by a young man with six visible piercings on his face. He was a valued employee, and the practice did not want to lose him; but they had strong objections to his appearance.

Becker approached the situation by explaining to the young man that patients who came into the office may be from a different generation and could be offended by his appearance. Still, the employee put up some resistance to removing all of his piercings for fear they would close up. So Becker worked out a compromise in which he was permitted to wear a few “less grotesque” earrings and wear flesh-colored piercings on the rest of his face. “Now he looked like he had pimples on his face,” laughs Becker, “but it was no longer painful to look at him.”

Becker even enlisted the help of his coworkers, who liked him and didn’t want to see him go, to encourage the young man’s transformation. “As he gradually got these flesh-colored earrings, other staff members would comment, ‘That looks really good, Jake.’ And even management - even the physicians - said, ‘Hey Jake, those are great earrings.’ So he was feeling that he was looking good and his appearance improved, and he didn’t fear his piercings would close.”

That may seem like a lot of effort to expend on one employee, but Becker knew that good front-desk staff aren’t easy to come by, and eliciting the young man’s input on how to solve the problem did not arouse unnecessary resentment.

Robin Richman, MD, the chief medical officer of Fallon Clinic, one of central Massachusetts’s largest private, multispecialty practices, agrees that taking an approach that encourages communication when making office policy changes greatly encourages employee buy-in.

“Try to have a dialogue when complaints arise,” she suggests. “You may not change your policy, but get back to the person who ventured the suggestion, and say, ‘We looked at it, we pulled a group together, we’re actually going to stick with what our original policy was, and this is why.’ Be transparent about your thinking process. That goes a long way. People may not be thrilled with the final result, but at least they understand.”

Merrilee Severino, a practice management consultant in Seminole, Fla., adds that when implementing policy changes, no matter how small, it’s crucial to emphasize the positive - even if you have to dig deep. For example, if an office is transitioning from business casual dress to uniforms that the office will pay for, highlight the fact that employees will no longer have to invest time and money into their workplace wardrobe.

If it’s a change that is made in consideration of worker safety, such as banning open-toed shoes, stress that the practice is making the change to protect their employees. “Even if it’s just, ‘People will approach you with a more professional attitude if we project a more professional appearance,’ try to find some sort of positive in the change, and use that approach,” advises Severino.

Wishon-Powell also likes to stress the positive in such situations. She acknowledges that enforcing professional dress codes, particularly among younger staff, is a “major problem” in the practices with which she’s worked.

So she advises her clients to establish their expectations right from the start. “Tell employees that they are professionals, that they are in a customer-service industry, and that they are expected to treat the customer/patient in a manner that is consistent with being professional, and that means looking the part … Give them the exact parameters of what that means. Not just ‘Look nice.’ Because looking nice to me and looking nice to you are two different things.”

It’s not fair!

Why was she promoted, and not me?

I’ve been here much longer.

I always knew the doctors liked her better.

Usually workplace promotions are perceived by the employees who earn them as occasions for celebration. But many promoted workers can tell you it’s not the bed of roses they originally thought it would be. In-house promotions can bring to the surface previously concealed feelings of competition and jealousy or even inspire outright resentment and insubordination.

In some cases, the promoted person’s peers will be truly happy for her and applaud what they feel is a well-deserved upward move. But in others, staff will feel the promotion was one based on favoritism rather than merit, and they will not mask their displeasure. Becker says that if management has the luxury of truly knowing their office’s dynamics - which is more likely to be the case in smaller practices - they may want to take aside and explain to the individual employees from whom they expect the most resistance why their coworker was chosen, and tell them that they expect them to respect the decision.

Wishon-Powell emphasizes that when promoting from within, a practice’s management team and physicians must give the newly appointed supervisor their “unequivocal support” and recognize her expanded authority. “Because if they waver on that, the promoted person will never get respect from her former peers,” she says.

Severino adds that it’s a good idea to follow up staff promotion announcements with memos that explicitly describe the promoted employee’s new duties and lists the individuals or departments she will now supervise. “Tell your team that the practice expects its staff to give this person the same courtesy and respect they would to any other person,” says Severino.

“I think that it may be harder on the manager who just got promoted sometimes than it is for other employees,” says Kronauge. “They must learn new management skills and how not to be ‘the coworker’ any longer.”

Wishon-Powell agrees: “You are going from someone’s peer and coworker and sometimes friend to supervising them. … You can’t be their ‘best friend’ anymore. You can’t go out to lunch with them everyday, you cannot retain a sense of peer-to-peer relation. There must be some line drawn now that you are the supervisor.” She suggests discussing these issues with the employee you wish to promote before making the announcement. Ensure your new supervisor is prepared to deal with these issues before she learns she may not be up to the task.

Severino holds one of her own promotions up as a shining example of how a practice can announce personnel changes in a way that proactively defuses any anticipated animosity. “We had a staff meeting to announce the change that was going to take place, and instead of focusing on the fact that I was the one who was assuming that position, we focused instead on the position itself,” she explains. By doing so, she says, the limelight was diverted away from her promotion above her peers, and instead spotlighted the roles and responsibilities of the position she was assuming. It made her transition much more seamless, says Severino, and her coworkers did not begrudge her the promotion.

Benefits bedlam

You know your overhead costs better than anyone. You know how much it costs to rent office space, purchase new equipment, pay for supplies, and keep yourself marketable. But your staff doesn’t. And you cannot assume that they do. Although they may respect you, they often also think that you are raking in millions compared to their own self-perceived meager salaries.

So when your calculations reveal that your practice is in the red and you must cut corners to keep your business - and the livelihoods of those you employ - afloat, don’t be surprised when your staff doesn’t see it the same way. Remember that they do not have access to the bigger financial picture that you do, and you must gently enlighten them when belt-tightening becomes necessary.

It’s easier to identify the wrong way to broach these topics with your staff than to plan for the “right” way. For example, keeping your employees entirely in the dark until you’ve made an executive decision concerning their benefits package is unlikely to get a warm response when they receive your e-mail announcement out of the blue. Severino has seen this happen, and she recalls the fallout as “very, very ugly.”

The staff with which Severino was working was called into a meeting via e-mail, at which they were informed in short order that the practice had switched to a new retirement plan. “It was, ‘We’ve done this,’ as opposed to ‘This is what is going to happen,’” Severino recalls. “And I think that’s what soured the entire staff. Because that affected everyone’s vesting schedule. Some people had been there for years and years and were fully vested, and now all of a sudden we have to start all over again with a new plan and go through the whole vesting period again?”

Such griping can be diminished, says Severino, even if the outcome is the same. She advises physicians and management staff to tell their employees “sooner rather than later” when they are considering benefits changes of any type. And if it’s at all possible, give your employees some decision-making ability, however small, to allow them to express their preferences when it comes to their benefits. “If you can give them any type of choice in the situation, it makes them more accepting of the change,” says Severino.

Becker recalls that she was once called into a practice whose overhead costs had spiraled out of control, and the physicians were operating in the red. They were currently offering their staff a very generous insurance plan with very low copays and no required referrals. Becker suggested that the physicians instead offer their employees a less-expensive HMO that entailed higher copays for office visits and pharmaceuticals, physician referrals, and a slightly higher premium. But rather than thrust the new plan onto the practice’s unsuspecting employees, Becker incorporated the office staff into the decision-making process.

“When we went to the staff, we were quite honest,” she recalls. “We told them, ‘This is what your insurance costs in addition to your salary,’ because lots of people don’t understand that. We then told them that we can do one of two things: go with a less-expensive HMO carrier or perhaps have to cut a staff person and have everyone work harder to keep up with overhead expenses.”

Becker says the choice wasn’t meant to be a scare tactic: The physicians showed their employees exactly what their overhead costs were and explained to them why they had to present them with this uncomfortable choice. “The employees seemed to understand,” says Becker. “And although they obviously weren’t thrilled about it, looking at the alternative, they accepted it less grudgingly than they would have if we just said, ‘OK, we’re changing the insurance, and now your copay is going to be higher.’”

Don’t assume

When it comes to helping staff adapt to change, whether you work in a solo or large multispecialty practice, physicians and management should avoid making what they may consider to be “no-brainer” assumptions.

Women are more self-conscious about their appearance than men. Therefore, you can expect your female employees to be more resistant to dress code changes than their male counterparts. Really? Recall Nancy Becker’s young male receptionist. The value he placed on his physical appearance far outranked those of his female coworkers.

Employees who are promoted will invariably be resented by their former peers whom they must now supervise. Not necessarily. When Merrilee Severino’s supervisors depersonalized her promotion and focused instead on the position she assumed, her coworkers did not begrudge their new supervisor her success.

There is no easy way to cut back on staff benefits. Just bite the bullet, announce the change, and wait for the dust to settle. … Well, your employees probably won’t be happy in any case. But being transparent about your practice’s finances and involving staff in benefits decisions goes a long way.

So yes, change is constant, and it is difficult. But as with so many managerial tasks, effective leaders who think outside the box rather than rushing to judgment can help your staff adjust to workplace transitions large and small and still maintain the high morale that accompanies a teamwork approach.

Barbara A. Gabriel, MA, is the associate editor of Physicians Practice. She has served as editor and writer for numerous healthcare publications over the past 10 years. Barbara can be reached at bgabriel@physicianspractice.com.

This article originally appeared in the April 2008 issue of Physicians Practice.