> Starting and Running a Practice

Leading Culture Change

Leading change and building your team by hiring exceptional employees 

Building a successful practice requires many skills that are not typically developed during one’s medical education: developing a sound business plan, cultivating a set of core values that are shared by your staff, identifying the best persons to hire and matching them with appropriate job duties, among many others. While many of these skills will grow out of experience, expanding your background of basic management knowledge can help provide you a framework for essential business decisions.

There is no shortage of literature on these topics from the business community, ranging from the most erudite microeconomic and quantitative analytical theories to “self-help,”- type publications espousing such insightful observations as “leaders lead!,” and so on. After spending some time wading through this diverse and often low-yield source material, a few key guiding principles seemed to stick, particularly on the subjects of leading culture change and developing sound hiring and team-building techniques.

In a classic text, “Leading Change,” Harvard academic John Kotter analyzed hundreds of companies of all sizes, evaluating their success at achieving a sustained transformation in culture and business practices. From this analysis, he identified key steps to transforming an organization.

While this work was aimed at corporate managers and executives, there are strong parallels to medical practices of all types—large groups, academic centers, even (and especially) smaller single-specialty and even solo practices—and in fact our field truly seems ripe for these ideas as we place so much emphasis (and rightly so!) on providing excellent dermatologic care that we sometimes neglect cultivating a sound business culture. Examples of this abound. You may join a well-established small group comprised of several dermatologists nearing retirement and a long-tenured staff that seems unwilling to embrace new challenges of modern medicine, such as instituting electronic medical records.

Alternatively, you may join a large multispecialty group and express a desire to build a laser and cosmetic practice, yet be rebuffed by management because, “no one has ever done that here before, and it seems too risky and expensive.” You may work at a center where there has been no prior emphasis on providing exceptional patient service, which is the lifeblood of a growing practice.

Initiate change

Initiate culture change by establishing a sense of urgency in your practice. Identify realities of where your team is failing, and discuss developing opportunities for future success. “We will be penalized X% if we do not adopt EMR by X date, there is no way around that. If we work together now, we can institute a system we are reasonably happy with, avoid the reimbursement penalty, and build a more efficient practice.”

Next, form a guiding coalition of staff (other physicians, managers, nurses, etc.) to lead the change process. This group will help clarify the vision and define steps to making it a reality. Using the example above, this group will identify the best EMR (most cost-effective, links up easily with local hospital, etc.) available and define the steps towards customizing it to your practice plan. Touching on the other examples, the “change coalition” would delineate how building a cosmetic practice makes sense economically and identify the best devices to rent or purchase. The coalition could outline specific steps to transforming the practice into one providing excellent patient service. After this vision has been developed, it should be communicated clearly and consistently, and initial concrete steps taken to see it become a reality.

Secure change

Help secure the gains you make towards improving your culture and company practices by creating “short-term wins.” Small yet quantifiable victories will provide continued momentum for your plan. If you are emphasizing patient service, consider comparing surveys given to your patients before and after new standards have been set in place, and celebrate concrete improvements. Consolidate and institutionalize your new approaches by clearly linking your new practice technique to successes, and by rewarding employees who have “bought in” with leadership positions. In time, the transformation that had seemed so radical to others when initially proposed will become part of the character of your practice.

Translating Goals and Values

A large part of this last step—translating the goals and values that you have identified as conducive to sustaining a successful practice—into the very fabric of your team, requires that you identify and mentor the right individuals that comprise your staff. Even the best HR managers will tell you that even after an extensive interview process, finding the right folks for the right jobs is somewhat of a crapshoot. Still, there are a few key guiding concepts that have been shown to improve the chances of hiring future stars of your team.

First, make sure your job posting reaches your target audience. Instead of using a traditional approach such as posting an open position on a major job search website (where you may receive hundreds of resumes, yet qualified applicants for the listed position), consider using newer social media tools such as Facebook or LinkedIn to help ensure the job listing is seen by potential applicants of the right background for the job. You can thereby leverage your connections and relationships to help identify a perhaps smaller but higher-yield cohort of potential employees.

When you actually meet a job applicant, it is critical that you accurately assess his or her fit with your practice’s culture. This is what really determines the success or failure of your vision. Clearly articulate the character and values that are important to you. For example, “We really emphasize patient service here. Our staff makes eye contact with every patient and greets him or her by name and with a smile.” Some candidate will self-select out if they feel they will not fit in with even basic practices. Many business authors also recommend actually observing applicants interacting with others. A candidate may tell you that he agrees with your group culture, but ideally you will actually see this during the interview. Consider asking a prospective employee to demonstrate core values during a simulated patient care situation.

It is also important to remember you are trying to match an applicant to a specific type of job; make sure you understand the skills or personality best suited to the position and compare these with those demonstrated by the job candidate. If, for example, you are looking for someone to lead your transformation to using EMR, at least some background in computing and using electronic records is probably paramount. Alternatively, if you are looking for someone to help ensure patients have as good an experience as possible while in your office, strive to find someone whose personality exudes compassion. One of the best nurses I have ever come across in surgical dermatology had a background as a preschool teacher before becoming a nurse—her skills managing two-year-olds translated beautifully into handling fussy patients and physicians alike!

Highlight the positive aspects of your practice culture during the interview in order to begin to cultivate the prospective applicant’s investment into your team’s practice values before he or she even starts. Discuss your goals for each employee. “We want each member of our staff to be fulfilled both in and out of work because we feel this balance leads to our performing the best patient care possible. To that end, we have developed flexible working arrangements to ensure each of us is able to spend high quality time with our families.”

Finally, contacting an applicant’s references often provides the best modicum for truly understanding his or her likelihood of succeeding as a member of your staff. This subject is certainly worth of a dedicated discussion. Key tips include ensuring you are speaking with an objective supervisor (rather than a good friend) who has spent significant time observing the prospective employee in a work capacity. Additionally, ask for objective measures, “of all the nurses you have supervised in your position as charge nurse, in what percentile would you rank this candidate?” It can also be exceedingly helpful to ask for a description of a time where your applicant encountered a disagreement or conflict in his or her old job. It is amazing how many character traits can be revealed by the recounting a specific story of how someone navigated a difficult situation at work.

In conclusion, instituting a needed transformation in your medical practice—whether business or cultural or both—requires a sound vision and diligent execution. This is not a linear process, there will be victories and setbacks, large-scale adjustments and fine calibrations. Hopefully some of the business ideas outlined above will help you get started, as they have benefitted me early in my career.

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