Staff Development: Give Peace a Chance

“No gum-snapping.”

That’s what one practice’s office policy manual now includes, after one compulsive offender irked her workmates once too often.

At another practice, a family physician and his assigned nurse tattled continuously on each other to the practice manager “mom” - for eight years.

Still elsewhere, two job-sharing administrative employees waged a silent but vicious “the stapler goes here” war, with victory - and the stapler - flip-flopping accordingly, depending on who was working that day.

Believe it or not, these are true-life scenarios. Most every medical practice experiences similar interpersonal issues, ranging from needling annoyances - “I can’t work with someone who giggles/sniffs/belches/clacks her dentures all the time” - to down ’n dirty fisticuffs in the hallway to wallet-emptying lawsuit embroilment.

Do skirmishes such as these amuse us when retold at the water cooler? Oh, yes. But if such issues are ignored or handled improperly, the results can be serious: For one, staff morale can plummet, stunting work output and allowing a negative atmosphere to infect the office. This can be expensive. According to a recent Gallup poll, negativity in the workplace costs the U.S. economy nearly $300 billion a year in lost productivity.

Patient care and patient satisfaction may plummet, too. The negativity caused by an office staff locked in chronic conflict will trickle down to your client base, and ultimately redirect many dollars from unhappy patients who ask to have their records transferred to a kinder, gentler practice.

Not so amusing.

Certainly, you want a friendly, flexible atmosphere where employees feel free to express themselves, but where they also honor the practice’s policies and culture. How can you build - and lead - a cohesive, communicative medical team so that everyone will work as needed yet still enjoy coming to work everyday?

Play nice with others

Think about it: You’ve got a small space with a lot of people trying to work together at often stressful jobs. Interpersonal problems are a “when,” not an “if,” which makes it all the more important for everyone to re-read the peer etiquette sections of Emily Post, Miss Manners, Dr. Phil, or any other guru of good behavior. One common breach of decorum?
The cancer of unified teams: Blamecasting, especially across departments.

Shepherd Eye Center’s practice administrator Christina Kennelley agrees wholeheartedly: “One of the biggest problems in departments is not appreciating or understanding what another [department] does - ‘It’s their fault, their job, they’re not doing it right.’” To minimize this bond-breaking behavior, Kennelley says they cross-train their employees, leading to a much deeper understanding of the interrelatedness of all jobs.

There’s nothing like blame to gum up the administrative works. It’s embarrassing to be blamed for something, and how tempting it is to try and pass it along like playing hot potato at a birthday party. This, of course, hurts both productivity and staff relations. The antidote? Incorporating a mindset of personal accountability, says Kennelley.

Kennelley speaks from personal experience. Shepherd Eye Center, with offices in Las Vegas and Henderson, Nev., recently experienced a period of staff discord after the practice grew rapidly. “People were feeling less cohesive,” she says. But instead of just gathering the staff together and lecturing them on the evils of tattling, gossiping, and passing on blame, she sought the advice of a consultant, who suggested a book by organizational consultant John Miller, titled “QBQ! The Question Behind the Question.”

“I made it required reading for the entire staff; it’s a really fast read,” she says. “Then we had a big staff meeting about it, and I had someone come talk about it who’d read the book too.”

Before invoking the QBQ program, Kennelley says, “I would get fingers pointing at the front window saying ‘Those people are making mistakes. They don’t know what they’re doing.’ So with QBQ it’s ‘What can I do to help out?’ and ‘Can I go down there and help them?”

Now, if Shepherd Eye Center employees catch a coworker “doing a QBQ” they publicize it, she says.

Miller’s stance is that personal accountability is critical to moving beyond blame, taking ownership, and finding solutions. Relations between staffers at Shepherd Eye Center improved dramatically. “It’s a constant process,” says Kennelley. “It’s hard to look at yourself and say ‘What did I do wrong? How can I make this better?’”

To support personal accountability, keep your staff on track by performing regular “checkups.” Set an open-door policy, with a safe avenue for voicing concerns and a well-defined path for resolving a problem. Arrange for your staff to attend workshops on conflict resolution - or have an expert come in - to teach them how to confront issues properly, without escalation. If any unpleasant incidents do occur, document them carefully, and when following up, be sure to stay focused on the behavior, not the personality.

Go team!

Unless you’re starting up a brand-new practice, you already have an assemblage of people you call your staff. Do they function as an integrated team? Or more like warring departmental mini-fiefdoms? This matters: A 2001 joint study by the National University of Manchester in England, and the New England Medical Center in Boston, found that a solid, interactive staff working in a positive environment is much more likely to provide overall high-quality care.

A dysfunctional team will show some or all of the following symptoms: a stress- and tension-infected office environment, reduced efficiency and productivity, dwindling morale, and ever-increasing turnover.

And there’s nothing like negative tactics by you to quash team success: If you use criticism to correct your staff, then fear of reprisal will depress communication, sometimes to the point of withholding information. Such suppression could have dire consequences, as the information could be vital to patient health. Worst-case scenario? Loss of physician support by the staff, retaliatory behavior, failure to assist, lawsuits, malicious sabotage, and even workplace violence.

Actual violence sounds exaggerative. It’s not. More than 1 million people are assaulted in U.S. workplaces every year, with the healthcare field four times more at risk than general office environments, reports the Bureau of Labor Statistics.

Happily, much of your staff conflict will resolve itself if you can find ways to strengthen team solidarity across the entire practice. Consider the following criteria outlined by physicians Kevin Grumbach and Thomas Bodenheimer in the March 2004 issue of the Journal of the American Medical Association:

• Set specific goals with measurable outcomes - If you don’t know where you’re going, you’re not going to get there, are you? Define this with a specific practice mission statement. Post it in multiple locations around the office. Then, based on that mission statement, set some practice goals. Include the entire staff in the planning, to a greater or lesser degree, as appropriate. Even the most junior staff members should feel that their ideas matter. A sense of ownership will seep into all your employees. When setting your goals, translate them into specific dollar amounts as accurately as possible, and then build an annual budget off of them.

• Devise functioning clinical and administrative systems - Do you have standard protocols for repetitive work, such as prescription refills? Notifying patients of their lab test results? Scheduling and confirming appointments? Reordering supplies? Smoothing out the work flow wherever possible will greatly ease staff tension and finger-pointing, not to mention eliminate excuses for low performers.

• Determine a clear division of labor - Who does what? What if the regular person assigned to a task is out sick unexpectedly? Do you have contingency plans ready? Turf wars often result from vagueness in this area. Also take a hard look at your employee organizational chart. Do current reporting assignments make sense? Are they too complicated? Consider a “flat” staff architecture, such as that used by the Physicians Practice 2006 Practice of the Year contest winner, Family Medical Specialists of Texas (See “Ch-ch-ch-changes” in the November/December 2006 issue of Physicians Practice).

• Provide adequate staff training - Are your employees qualified to perform their jobs? Shoring up skills can boost confidence, mood, and outlook, resulting in more positive staff interaction. If workers feel competent to perform their jobs, they’re more likely to do them in a positive frame of mind and be nice to work with. Consider cross-training them on other jobs too, so you can adjust for absences or seasonal demands.

Also, consider this related aspect to staff training: certification. Most of your medical staff can become certified in their areas; practice management expert Owen Dahl discusses this in Physicians Practice Pearls. The benefit? Increased pride in one’s work equals a happier employee, which equals someone nicer to work with, which equals more satisfied patients, which potentially equals increased revenues.

• Communicate effectively - You have verbal, paper, and (hopefully) electronic flow within your practice. Is it mapped out? Emphasize the importance of honing communication skills. Listen actively. With few exceptions, avoid interrupting a speaker. Respect others’ opinions. Most of all, avoid passing judgment, even with seemingly innocuous comments, such as “Oh, acupuncture is useless.” You’re certainly entitled to your opinion, but an “is” statement is not an opinion. It’s actually an often unconsciously provocative attempt to set a standard in a way that begs to be challenged. Better: “I don’t subscribe to acupuncture.” Fine. You don’t have to. And you haven’t insulted those who do.

Hire power

Nothing can disrupt an otherwise happy collection of workmates more than changing staff. The trick, of course, is to hire the right person, one who seamlessly melts into the existing work flows, embracing your practice’s culture as her own.

Sure, easy to say. But Alpenglow Medical family physician Daniel Griffin knows firsthand why the hackneyed cliché “Good help is hard to find” persists: because it’s true. He recalls a former administrative staffer who, after just two months on the job, demanded that five other employees be fired because she didn’t get along with them. His response: “We discussed the fact that perhaps it would be better if she left instead.”

Even a staffer already on board can become a poor fit if circumstances change, such as when Griffin expanded his Ft. Collins, Colo.-based solo practice to four providers. To help with the increased load, he hired a second medical assistant. “It wasn’t very long before I realized my [current] LPN was not an ideal employee,” he says.

The new MA vastly outperformed the higher-paid nurse, who was always running behind. Worse, the LPN adjusted practice policies to suit her liking, such as not bothering to weigh patients; she’d just ask them and write down whatever they said. This probably went over just fine with some but Griffin understandably objected. “I said, ‘Excuse me, there’s a scale in every single exam room. Why do you think that is?’”

The nurse was let go within one week of the second MA’s start date.

But it’s a never-ending battle. Griffin also fired a biller under circumstances very similar to the LPN scenario; for a while, two part-time replacements worked out well. Then the practice grew again, so he brought on another biller to help out. “She left within a day,” he says, after finding herself unable to mesh with the practice’s cooperative style. Yet she seemed “fine” in the interview.

Ah, the interview. How can you be sure you’re conducting one that truly illuminates a candidate’s capabilities? By asking “What if” questions, says Cathy Treadway, a practice management consultant who specializes in human resource team-building. For example:

• A patient, just diagnosed with cancer, comes in unexpectedly. She is terrified, full of questions. The doctor is not available. What will you do?

• A doctor comes up to you at the front desk, very angry with the way you scheduled his patients. He demands an explanation. There are many patients around within earshot. How will you handle it?

“I put forth ethical questions and other problems and see what the answers are, rather than asking, ‘What was your biggest challenge in your last job?’ This I’ve found gets them thinking on their feet,” says Treadway, a senior consultant with Medical Management, which offers management services to medical practices. Treadway is not looking for one correct answer; certainly there are many solutions that blend the black and white of such issues. Rather, it’s a sense of the candidate’s values and belief system that interests her, and whether these will meld with the practice. “You put them on the spot and see how they’ll deal with it,” she says.

This is not to say that job skills, proper certifications, and work history don’t matter, because of course they do. But if you’ve got a candidate who’s a tad short on experience but she’s unquestionably positive, enthusiastic, and compassionate, you’ll likely do better hiring her than someone else who offers stellar credentials but flatlines on the care-o-meter.

Still, expect no guarantees. Although he’s pleased with his staff at the moment, David Albenberg of Access Healthcare in Charleston, S.C., says that determining during an interview whether a person will make a good fit is nearly impossible. “It doesn’t seem to matter what we do, whether we go out drinking with them or meet in a formal setting,” he says. “The one we took out drinking, she rose to the occasion. But then she turned out to be an alcoholic. She had beers in our immunization fridge.”

When we just can’t get along

For nearly a decade, a young doctor and his seasoned nurse at Santa Paula, Calif.-based Westside Family Practice went at it: He thought she did things too fast, failing to complete tasks properly. She thought some of his clinical protocols were erroneous. He’d say hurtful things to her. She’d sass him about how her time was valuable, too.

Practice manager Jeanice Lambert had the lucky task of negotiating regular peace talks between the two to maintain an uneasy détente. She says the two were teamed up when the physician, fresh out of school, came on board. “We said [to the nurse], ‘We need you to train him, and let me tell you, she took it literally.’ He’d want his trays set up a certain way, and she’d say, ‘Now that’s not the way you do it.’ They were both very stern about it.”

One kerfuffle after another kept the whole office stirred up, says Lambert. “It was a constant battle.”

But not everything was negative: The physician became enormously popular; the workhorse nurse could keep up. And they both did honestly try to improve their rocky relationship: He learned about conflict resolution and adjusted his communication habits while she owned up to her indiscretions, and strove to be more attuned and acquiescent to his needs.

But love-hate was the best they achieved. “He dearly loved her and took care of her, and she loved him too. But they just bugged each other,” Lambert says. After eight years, the nurse retired.

If you’ve been struggling with a personality conflict for a long time and have exhausted all avenues of resolving the issues, then accept the fact that occasionally personalities just don’t mesh. Can you switch assignments around for more harmonious interactions? When the original nurse finally retired, Lambert says that “from the minute [the new nurse] started working with him, I knew. She had a different approach. She stays a step ahead and anticipates. Now I never hear a ripple.”

Join the culture club

“Culture is a vague concept, but very real when it comes to staff harmony,” says Albenberg. A clearly defined culture embraced by the entire practice is key. But what if you don’t really have one? Then create one by taking time - both on and off the clock - to cultivate bonds between staffers. Albenberg schedules quarterly outings for his entire staff. “It reminds us why we’re doing this. We all share funny anecdotes,” he says. Certainly, laughter goes a long way to strengthen the “We’re all in this together” feeling.

Sometimes the outings are service-oriented. “We cook at a homeless shelter, bring food into the Ronald McDonald House, or volunteer at a 10K,” Albenberg says. “It doesn’t really matter what it is as long as it’s not for us.”

Griffin believes in staff outings too, on a monthly basis. Occasionally, the excursions are more substantial, such as a four-day, all-staff trip to Mexico a year and a half ago. “That actually helped a lot,” he says. He hopes to do something similar again in the near future.

In-office activities are just as important. Alpenglow Medical meets every Monday for a one-hour practice-wide staff meeting. “The back and the front offices also meet once a week,” says Griffin. This does wonders for ironing out work flow issues and resolving minor grievances before they become major issues.

The trick is to promote a sense of community from what is essentially an arbitrary collection of people. “It’s about creating that culture together,” Albenberg says. Will everyone be touchy-feely, best buddies? Unlikely. But they don’t have to be. “It’s not whether a staff person is ‘nice,’ but whether they’re all working together.”

Why? Because your patients will know. From the minute they sign in at the front-desk until they’re walking out post-exam, the care they receive will be interwoven with your practice’s group attitude. Just as dogs can smell fear, patients may be able to sense when your medical “family” is struggling.

You’ll be able to tell which individuals in your practice truly “get” your culture, as those people will be magnets of productivity; indeed, Access Healthcare has one. “We have one particular person here who when she’s here things just seem to flow,” says Albenberg. “Everyone likes to be around her.”

And from where does that culture flow? The physician. Basically, you’re a walking, talking example for everything you want from your staff. So if you want your staff to get along with each other, then you must follow the rules, too. That means showing appreciation; staying calm in the face of conflict; keeping promises; accepting responsibility for mistakes; being empathetic, nonjudgmental, and tolerant of human frailty; accepting criticisms and suggestions; and backing others up if patients treat them poorly (with patient-retaining diplomacy, of course).

The bottom line is to be mindful of your own actions, because, good or bad, you’ll lead by example. You’ll be glad you made the effort, and so will everyone else. “Overall, there’s nothing better than a jelling staff, one that’s all there for the same reason,” Albenberg says. “Patients can feel that. There’s no doubt about it.”

Shirley Grace, MA, the senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the September 2007 issue of Physicians Practice.

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