No More Sacred Cows!

Is there a "sacred cow" on your staff? Not the four-legged kind. I'm talking about the person who is disruptive, unproductive, and demoralizes others, yet is immune from criticism and discipline.

It's easy to spot this creature. He is never held fully accountable for his work or behavior. In extreme cases, staff may fear they will be pushed aside or terminated for even suggesting that this person doesn't carry her share of the workload.

Maybe "untouchable" is another word to describe the person who goes on month after month, year after year, causing dissention and underperforming without suffering the consequences.

How do you know you have one of these people in your practice? Look for the person who:

• fails to complete work, so other staff must do it instead;
• resists improvements that might diminish status or expose shortcomings;
• sabotages efforts to change;
• undermines discipline and morale;
• stalls or derails projects; or
• causes excessive expenses.

"Some sacred cows are control freaks," says Frank Mihoda, a CPA in Denver who specializes in advising medical practices. According to Mihoda, an individual can build a power structure by becoming the only one who knows how to do a critical task. He may try to get rid of anyone who questions what he does or how he does it. Even outsiders, like the practice's professional advisers, can be targeted if they pose a threat.

Open your eyes

Who elevates an individual to sacred cow status? In medical practices it is usually a physician. So the next question is: why has one person been given such favored status and allowed to disrupt the practice? You probably never intended for it to happen; you may not have known the deification process was underway until it was too late.

The structure and small size of the typical medical practice make it fertile ground for the creation and nurturing of:

• The nurse whose seniority and trustworthiness get her appointed office manager with the unquestioned support of one or more key physicians -- even if she is not qualified for the position.
• The office manager who is the spouse of one of the physicians.
• The staff member who is a relative or close friend of the office manager.
• The staff member or manager whose advancement was supported by a physician who won't admit later that the promotion was a mistake.
• The staff member who makes sure that he is the only one who knows how to operate the computer system or handle some other critical task.

A little less common but not rare is the staff member who gains special status by helping to cover up a physician's extramarital affair. Then, there's the staff member who is romantically involved with a physician.

I am sometimes amazed to see how far some practices allow their personnel situations to devolve.

As a consultant who has worked with many medical practices over the years, often my first clue is just sensing an atmosphere of tension. In these practices, I find people giving brief, guarded answers to such simple questions as, "Why are charges not posted in a timely manner?" Or "Why do patients wait on hold for so long when they call?"

I find the most difficult engagements are the ones in which people are reluctant to admit that a staff member is incompetent yet untouchable, or creates morale problems that the physicians won't do anything about.

Dislodge the sacred cow

Dislodging a sacred cow is difficult. You must fully understand the situation, the problems that the person's behavior causes, and your options to correct the situation.

There is no simple step-by-step process because situations vary widely and the problems created by the privileged person are different in each case.

Because resolution is elusive, not to mention potentially hazardous or embarrassing, many physicians procrastinate and go into management paralysis. However, allowing the situation to continue only will increase the damage and make the problem more difficult to correct later on.

I recommend following a four-step process:

• understand the situation,
• list options,
• estimate the worst repercussions of each option, and
• take carefully planned action.

Gather facts

Start your investigation by interviewing those closest to the situation. Since information you gain in one interview will often lead to more questions, be sure to document interviews and label every document you obtain.

Because investigators must gain the trust of the people they interview, it often helps to use a practice consultant, accountant, attorney, or other outsider. Your practice's legal adviser may be able to recommend a business expert skilled at internal investigations.

The investigator should make clear to interviewees that she will do everything possible to maintain confidentiality and contain repercussions. She must also make clear that it may be necessary to disclose some information sources in order to appropriately make changes.

Interviewees will be more candid if one-on-one interviews are held off-site such as at the hospital cafeteria, another office, or by telephone.

The interviews may produce much useful information but could bring to the surface a tangled web of operational issues and personality differences. A good investigator will separate fact from rumor, and know which comments reveal genuine issues as opposed to interoffice jealousies or personal agendas.

Consider options

The first action many people think of when dealing with a sacred cow is to terminate the person. But other steps could better serve the practice, especially if the problem employee did not create the situation and is willing to change.

Helping a staff member correct inappropriate behavior preserves the value of her talents and experience. Consider restructuring the person's duties or changing lines of authority. Write down expectations and consequences for failing to change the disruptive behavior and establish a timetable.

Maybe you can work out a reasonable plan for dramatic and lasting behavior change, but will this solution be acceptable to other physicians and staff? If retaining the problem person is likely to cause additional and significant damage to morale and performance, then consider termination.

If your practice used a proper and legal process to address the unacceptable behavior, including documentation of all discussions with the employee about her performance, then follow your practice's policies and procedures through to termination of the problem employee. If, as is generally the case with sacred cows, your practice indirectly condoned the inappropriate behavior by inaction, then termination might bring significant problems. You might as well face the fact that resolving the issue will not be pretty or easy, but will be far better in the long run than allowing the situation to continue.

Negotiate, then act

If your practice either created or condoned the situation  -- or both -- and the situation has been tolerated for a significant period of time, then consider an unconventional approach: negotiate with the individual to voluntarily leave the practice. When it works, this approach helps avoid complaints to government agencies or legal action. Review this or other options first with an attorney who specializes in employment law.

Brace yourself. These negotiations will not be well received by the sacred cow. Don't forget, this person probably likes the power, the control, the recognition, the money, or whatever else it is that her behavior and your toleration of it have produced.

Assemble evidence that shows why your practice cannot allow the situation to continue. Try to quantify personnel turnover, revenue loss, excessive expenses, work inadequacies, and low morale. Present these issues to the problem person. For example, say, "Our practice has a 50 percent turnover rate of staff and most of these people cite you as the reason they leave." Or, "You are frequently out of the office when staff need you." Offer to negotiate a reasonably fair solution.

What are your negotiating points? The problem person may be concerned about lost income, embarrassment, or low prestige if she loses her job. Try offering:

• severance pay,
• voluntary resignation before a termination action begins, or
• employment agency services to find a more appropriate position.

This final option is often the best choice when the problem person is the spouse of one of the physicians.

What's best for the practice

Some of these solutions sound like payoffs -- but their cost will be far less than the expense and stress of defending your practice against a wrongful discharge lawsuit.

The problem employee may argue that your practice allowed the work situation to exist for a long period of time, then suddenly reversed course and disciplined or terminated her for that same behavior. She may allege that she had every reason to believe her behavior was acceptable to you because it was tolerated without penalty for an extended period and she continued to received pay raises, bonuses, promotions, etc. And she may win that case.

Remember that you or other leaders in the practice probably had a hand in either creating or, at least, condoning this situation.
Don't let it happen again. Good communication with staff, access to managing physicians and consultants, and holding people accountable help foster a healthy working atmosphere in which problems are exposed and resolved before they turn into major issues.

Act now to avoid the development of sacred cows. Some of my clients have physicians' spouses managing their offices, but they are extremely competent managers. Since there's always the potential that staff in these practices might be reluctant to complain about the manager to the physicians, they are told to contact me confidentially with any complaints about the management. Consider using a third-party observer if you employ relatives of physicians in management roles, or if you sense any other forms of the sacred cow in your practice.

Just remember that whatever action you take must be justified and carefully executed. There is no one-size-fits-all solution. If you see a pattern of favoritism developing, deal with it quickly and properly before it becomes an established practice, a likely morale problem, and a potential lawsuit.

Paul Angotti, BS, is president of Management Design, LLC, a company that helps physicians to establish and maintain financial and operational control of their practices. He can be reached at angotti@management-design.com or via editor@physicianspractice.com.

This article originally appeared in the May 2004 issue of Physicians Practice.