Managing Staff: GO TEAM!

Susan Rapp “moonwalks” (badly, she admits) in the hallway, blares dance music before the office opens, and begs her patients to tell her funny stories.

She’s serious about her work as a primary-care physician but believes a fun atmosphere means that she, her coworkers, and her colleagues actually enjoy coming to work in the morning.

“It is really important to keep the enthusiasm going,” says Rapp, who practices in Walnut Creek, Calif. “And to support the people who support you. I do different things to motivate the staff. It is important to me to have a peaceful atmosphere.”

A negative, tension-filled office can cripple a practice. But by being lighthearted and better organized and by showing more appreciation to your staff, you can cut down on gossiping, back-stabbing, and other behaviors that, whether you realize it or not, get in the way of patient care and cost you money.

Misery loves company

You typically need a diagnosis before you can begin treating a medical problem. The same is true for an “unhealthy” office. So why are your coworkers unhappy?

“I can pinpoint three reasons,” says Rapp’s sister, Karyn Buxman, a nurse and president and founder of HumorX, a consulting firm in La Jolla, Calif. The first is what she calls the “Negative Nellies,” whose “mission in life is to be absolutely miserable, and it is their vision to see how many people they can bring down with them.”

A feeling of powerlessness can also darken moods. “What we see a lot in healthcare, from the nurses’ perspective especially, is a lack of respect and a lack of engagement. They don’t feel like they are pulled into the decision-making process, whether it is policies or office design,” says Buxman.

“The third thing is the overall umbrella of stress. They can’t bring in enough qualified staff. The mantra we hear is ‘We have too much to do and not enough time,’” she adds.

In addition to work overload, frustration builds when the division of duties is unequal or is perceived to be unequal. “There are types of people who will relinquish their task to another person, and this person will do more and more until they have a nuclear meltdown,” says Katharine White, RN, MS, a practice consultant based in Cranston, R.I. “You have people who stand around and gossip because their schedule is not matching what the office needs.”

White adds that the “cottage industry” nature of many small offices contributes to an unruly or nonproductive atmosphere. Practices that lack formal, written job descriptions, fail to conduct performance reviews, or suffer from a lack of leadership, will also have a difficult time keeping employees on track, she says.

Conversely, there may be an administrator who takes action, only to be undercut and “chastised” by the practice’s physicians. That allows problems to continue, White says.

Meanwhile, many employees focus so much on patients that the business or administrative aspects of the office get scant attention, which can rile other staffers.

“We have a lot of people who care so much about patients, to the detriment of themselves, so that they don’t really have anything to give anyone who is a colleague or a peer,” says Julie Fuimano, MBA, a nurse and an executive coach with Nurturing Your Success, based in Whitpain Township, Pa. “They may also have poor communication skills. They don’t know to deal with the woman who’s screaming, or maybe they do it themselves.”

Left unchecked, these factors cause relationships between office staff to devolve. “People end up in subgroups trying to figure out what to do, and more often than not they end up venting or complaining,” White says.

Don’t ignore personnel concerns because you think they don’t affect patient care. They do. Poor training and miscommunication are the two most common culprits of medical errors, and issues that arise among staffers can spill over into their relationships with patients.

Humor builds bridges

Research shows that people who feel no connection with their physicians are more likely to sue following a bad outcome. What better way for staffers to foster a bond with patients, and each other, than by sharing a laugh?

That’s the approach Rapp has taken since she joined her primary-care practice five years ago. She often starts the day by turning on dance music and cajoling staffers - including support staff who work in other areas and don’t typically interact with clinical staff - to let loose a bit. She wants everyone in the 25-physician practice to feel valued.

“I call up the girls in the phone room and have them come dance with me,” Rapp says.

Rapp employs humor with her patients too, which she says helps the practice comply with HEDIS measures. For example, she addresses the common problem of “white coat hypertension” - when the tension of being in a doctor’s office causes a patient’s blood pressure to rise - by using humor to get patients to relax. Her efforts often succeed in bringing such patients’ blood pressure within HEDIS-recommended levels.

“My sister often says, ‘Laughter releases endorphins,’” Rapp explains. “So I say [to patients], ‘Tell me the funniest thing that happened to you yesterday.’ I have seen the rate drop by 10 points.”

Buxman says humor is a much underutilized and easy tool to make work more enjoyable. Many healthcare workers, she says, “don’t wish to be humorless” but over time have “confused professionalism with being solemn.”

“My dad is a physician; my brother is a respiratory therapist. As a whole, they take themselves extremely seriously, but away from the workplace, one-on-one, they are an absolute hoot,” Buxman says.

Can’t find anything to laugh about in your practice? Buxman’s heard that one, too. “What we find is that many people need to raise their awareness. It is more important to see funny than to be funny. Start listening to the things people say.” (You can also subscribe to Buxman’s free monthly e-zine at www.humorx.com, which will tickle your funny bone.)

There are times when you just have to decide whether you will perceive life’s foibles as amusing rather than allowing them to upset or anger you. “What I am trying to teach people is to play with their pain. Most humor comes from pain and discomfort. We are not laughing about a good hair day,” Buxman says.

Even oncology practices can have fun. One that Buxman works with asked its staff members to cut out their favorite comic strips, which were laminated and kept in a bowl in the waiting room for folks to read and take home. Patients loved it so much they started coming in with copies of their own favorite strips to share.

Even meetings provide an opportunity for humor. Each time you hold a staff meeting, invite participants to “bring a funny joke or share a story,” Buxman suggests.

Turn problem employees into assets

Creating a pleasant work environment is challenging when employees consistently gossip and complain. But even the chronic whiners and ne’er-do-wells can be won over, says Fuimano. If the complainer comes to you, first offer praise. “Say, ‘Wow, I am so glad that you were able to identify that problem.’ Someone who complains and complains doesn’t feel he or she has any power to enact change,” Fuimano explains. “Ask them, ‘What should we do?’ Get them thinking. You can start to unleash their creativity. People want to be great; they just don’t know how.”

The same technique can work with gossips. “When you have someone who gossips, what they are usually doing is tearing people down. But the gossip has wonderful skills. They are good at getting people to listen to them and at disseminating information,” skills that can benefit the practice, says Fuimano. “Have that person be your secretary at the office meeting,” she recommends.

Sometimes the chitchat occurs because employees have too much downtime. Make a list of activities they can do during breaks between patients, “things that are in the queue that require time, such as filing or doing follow-up calls to patients,” White says.

Try not to blame or single out any one employee. You can bring attention to a problem - such as lights continually left on after the office has closed - by observing that fact without mentioning who might have been responsible, Fuimano says.

White says one quick way to diffuse clashes and bring employees together is to have them complete a special task or work in teams on some type of quality improvement project.

Be sensitive

Another way to ease office stress is to regularly show staff your appreciation. Rapp gives hers a card that says “You Rule,” or “You Rock,” with a summary of what the person did to earn her praise. “I always like to be appreciated by my bosses,” she says.

She has given out 15 to 20 such cards to staffers, rewarding them for their work with patients as well as with her. Someone who “brings me charts in a timely manner” or “squeezes a patient in the schedule” would earn the recognition, Rapp says, as would one complimented by a patient. Getting a card “became a big deal,” with workers competing to see who got the most. Five wins lunch with Rapp.

And don’t forget to spread a little green cheer too. The lament White hears is “the physicians thank me for a lot of things, but at a certain point they need to do a little profit-sharing. It doesn’t have to be a huge amount of money.”

Unhappy workers may stay with your practice because they “get little raises over time and have flexibility in their work schedules,” says White. “They are happy about that, but they are also looking for compensation. If the only acknowledgment is a thank-you and not dollars, it wears on them.”

Radiology Associates/Greystone, a six-physician group based in Providence, R.I., has many long-serving employees who function almost en masse as a “sisterhood,” says Lori DeCesaris, a marketing official with the practice.

The group went through a series of rapid shifts in the past few years, including automating certain procedures. Staff had to adapt to referral affiliations, use different billing procedures, and adjust to other changes. The sisterhood, as DeCesaris puts it, “was pissed,” and a battle was raging about which was more important, patient care or “clean” data.

After months of seeing the billing staff become upset over requirements that other staffers simply refused to comply with, DeCesaris brought White in to improve both office relationships and data accuracy.

Among the changes that were instituted were fancy dinners recognizing years of service among staffers and regular meetings held after work (for which the workers were paid and fed). Perhaps most important, the physician partners agreed to work together and close the leadership vacuum that allowed workers to strike their own deals with certain doctors.

Bonuses are being reconfigured to be based on productivity rather than flat amounts, and staffers are working together on quality improvement teams. Morale has soared, DeCesaris says.

If dealing with problem employees seems tough, correcting issues with wayward physicians is even more difficult. “Ideally, physician problems need to be addressed by other physicians,” she says.

As highly educated professionals, physicians may be resistant to criticism, White says.

An office administrator could step up to the task but must give feedback “in a way that the physician can hear it,” White adds. The practice’s written job expectations apply to physicians, too, and youcan refer to them with a physician in the same way you would with a nonphysician.

Know when to say goodbye

Sometimes your best efforts to placate an employee or calm tensions fall short, and you have to let someone go. DeCesaris did dismiss one worker whose departure made an “unbelievable” change for the better.

Fuimano recalls a practice that suffered for years with an incompetent receptionist. Managers hesitated to fire her because she had been with the practice a long time and although she didn’t fulfill her duties well, she was considered a “nice person.”

“They did end up getting rid of her, and her replacement is great. She can do so much more for them,” Fuimano says. Your new hires will start off right if you are clear about the practice’s mission and the “critical competencies” that you want your employees and colleagues to possess, says White. Stress that your practice’s focus is on your patients and their families first, but that the same care and attention should be shown to coworkers as well.

Communicate the practice’s “service standards,” White says, making it clear that “we are serious about this. We want excellence.”

If you hire someone who has technical skills but who can’t solve problems, is not a team player, and doesn’t relate well to others, you’re probably making a mistake. “With limited leadership, he or she can become the ‘problem person’ that everyone tiptoes by,” says White.

Buxman recommends “hiring for attitude,” saying: “You can teach the skills.” White suggests describing conflicts that have occurred in your office and asking applicants how they would handle such scenarios.

Take hiring seriously, and don’t pick someone simply because she has a pulse. Even if you are short-staffed and need to hire right away, you should be doing more than “putting a mirror in front of their face and checking for moisture,” Buxman says.

Ultimately, if unacceptable behavior is damaging your practice, it’s because “someone is putting up with it,” Fuimano says. “If you are not happy, it is your responsibility to change it. Employees do what they do because they don’t know any different, and they don’t have any other expectations for their behavior.”

With margins tighter than ever, “practices have to show more discipline,” White adds. In the past, “they made a lot of money no matter what. But they have to do things differently now.”

Theresa Defino can be reached via editor@physicianspractice.com.

This article originally appeared in the July/August 2006 issue of Physicians Practice.