Articles by JCS
The Intangible Key to Success: Management -- the Missing Link
By J.C. Smith, MA, DC
Perhaps the most difficult aspect of building and operating a successful practice is the most intangible factor of all -- management. While most practice-building seminars are quite capable of instructing clients in the many procedures that must be done, few seminars address the most important aspect of any business -- management and leadership.
First of all, management is not management is not management. And there is a huge difference between management and leadership. As it was once said, managers do things right; leaders do the right thing. Michael Gerber, author of The E Myth, speaks of the mindset differences between the technician, the manager and the entrepreneur. In chiropractic, we can relate his concepts to the mindset of the clinician, the office manager and the business owner -- the three hats that every DC must wear. The different management styles used by these three roles can be categorized as: 1) transactional management; 2) transformational management and 3) leadership.
Transactional management is involved with the steps it takes to process a product to a final conclusion. In chiropractic, assuming our goal is a completed case, the transactional management in our office consists of patient processing from the initial telephone call, consultation and exams, report of findings, informed consent, treatment plan, progress exams, and report at the conclusion of their care. From the beginning to the end of their intensive care period, many steps are involved in both patient processing and the financial process of collections. Without sound transactional management along each step of the process, patient dropouts and uncollected fees will result. On the other hand, with good patient management using case managers and a system of tracking patients, more cases will be completed and more money will be collected -- a definite win-win relationship for both the doctor and patient.
Transformational management is more difficult than transactional management in that it requires chiropractic staff members to be adept in people skills and educational skills. Assuming that most new patients are medically-tainted, chiropractically naive, costþconscious, health-negligent, skeptical and scared to death, unless you and your staff understand these hidden fears, worries and concerns and address their resolution, such cases will be doomed from the start unless you are able to transform these confused sorts.
Rarely has a new prospective patient come into my office already transformed to the chiropractic paradigm of health and spinal care. If you assume they are in agreement with your office's way of thinking, that's a fatal assumption that will only lead to premature dropouts. Without an effective patient education program aimed to reposition these wrong-headed attitudes, fears and worries that patients usually have, your hope of a completed case rests more on blind faith than professional management. An effective patient program consists of much more than showing them an expensive patient video!
In my office the transformational process begins with the first telephone call. My receptionist plants the seeds of conditional acceptance, our "three-day exam process," to name but a few of the management points we employ. If the prospective new patient is demanding unrealistic requests, such as to be treated immediately without proper exams, the receptionist is empowered to suggest the patient seek help elsewhere. We've learned long ago to weed out the problem patients who throw up red flag signals from the get-go.
While some DCs may choose to play in a chiropractic medical stop emergency room scenario, I've found this is definitely a lose-lose situation. For example, if you do succumb to this request to process a new patient in one fell swoop, the patient is left with two assumptions, both of which can sabotage your hope of a completed case. First, if the patient is given an immediate adjustment without proper transformational management and feels better, he mistakenly assumes that's enough! And if the patient is treated and feels no improvement, he mistakenly thinks, "I tried chiropractic and it didn't work!" Either way, you lose control of the patient in your haste to help them feel better instantly. Furthermore, when the patient who got some relief finally does have their inevitable relapse, then he again mistakenly believes that chiropractic didn't last, so off he goes to the orthopedist!
During our initial exam process, the second day is most important for learning more about the patient's issues of the head and heart. While most exams solely focus on the issues of the spine/body, out patient analysis form aims to ferret out the fears, worries and concerns that may ultimately sabotage their case -- issues of preexisting negative stories they may have heard; fears about being adjusted; money concerns (especially if they have no insurance coverage); time constraints; negligent attitudes; or whatever hidden agendas may be lurking deep within the new patient's mind that most often go undetected.
While my case manager is doing the initial patient spinal physical exam on the second day (we take x-rays on the first), she subtly inquires about these issues of the head and heart. "What have you heard about chiropractic?" is essential to ask everyone. "What brought you to our office rather than another DC?" is important to know to determine if this patient understands the unique factor of our office. The worst cases are those who are clueless about our office, often there with cross-purposes, not knowing how comprehensive spinal care occurs. Unless these questions are addressed and the patient's fears answered, these issues of the head and heart will dash your hope of a completed case.
Another tactic to transform the patient's mindset is the use of a comprehensive patient education program. At the end of my initial consultation, I mention to the prospective new patient a few seeds of thought, such as the concept of conditional acceptance and a treatment plan. "After the exams are complete, if I feel I can help you, I will outline a treatment plan to first help control your pain, and secondly, to help you stabilize your spinal weakness and to teach you how to prevent a relapse."
This plants two ideas in the patient's mind: not all patients automatically become patients; and second, that if accepted, the patient will be put on a treatment plan. This curtails two problems every DC faces with prospective new patients: first, it tells the patients that he/she will be accepted on the doctor's terms; and second, that in my practice, patients do not do as they please. While approximately 80 percent of DCs do not use treatment plans, without one, patient management is lost and compliance suffers. Remember, without a vision, people will perish; without a treatment plan, patients will disappear!
To plant these seeds and to inform the new prospective patient about my office, chiropractic care, and the nature of their involvement in this treatment plan, I distribute to them an audiocassette tape that I've made which discusses these issues and more: a short biography of myself, the unique factor of my office, the nature of spinal care, and what they will have to do to manage their spinal problems.
Also, I always give a quiz question to them, telling them that I will be asking them one question: What are the three principles of spinal rehabilitation? If they're really astute or know the answer already, then I will ask them how many joints are there in the spinal column? Making patients responsible for understanding their problem and chiropractic care beforehand is essential to transform patients. The last thing I want to hear from anyone is, "I don't need to listen, I believe in chiropractic!" My response is simple: "I don't want you to believe in chiropractic, I want you to understand it!" Too much of health care is based on blind faith, whether it's medications, surgery or chiropractic care. And blind faith is a difficult way to manage anyone.
Once the steps of transactional management of patient processing are in place to achieve more completed cases, and once transformational management is in place to create ideal patients who understand chiropractic care, the last type of management -- leadership -- is the glue in this entire process! Again, without a vision, the people will perish. The same can be said about the vision you give (or don't give) your staff and patients. Unfortunately, most young DCs are clueless about leadership concepts, let alone have acquired leadership ability. Too few chiropractors are innately gifted with leadership qualities, not have they developed these skills, since chiropractic colleges actually from students into individualistic, task-oriented people rather than team-oriented, people-oriented leaders who know how to build a team and lead it successfully.
Leadership is more than management by statistics, by wrath or by charisma. Leadership is bridging the gap between where people are and where they need to be. So, doctor, how do you bridge the gaps in your practice between amateur CAs with no professional education or experience, or with patients who can't even spell chiropractic, let alone know what it is and what they must do to achieve good, lasting results? Until you realize there's much more to management than simply yelling at people, few gaps will be bridged, few patients will understand your logic or treatment plan, and few staff members will evolve into real professionals without proper guidance, instruction and motivation.
As Tom Peters, author of In Search of Excellence, has said repeatedly: "You gotta care!" Caring about people, caring about the systems you employ in your office, and caring about the integration of the soft and hard technology that exists in every successful practice. It's more than just trying really hard; it's being effective. It's more than praying for success as much as it's developing a business process that works to create satisfied consumers. Seeking excellence is more than some high-volume, "Spines 'R Us" chiropractic office; it's getting people up a learning curve to become self-reliant and self-actualized.
Michael Gerber mentioned on his audiocassette tapes: "Where do you think all those dysfunctional children end up? As your employees!" Or as your patients, I might add! Unless you understand the huge problem you face to establish a corporate culture of shared values, your office will become a potpourri of ideas, depending upon who you ask. For example, your receptionist is the biggest gatekeeper of your practice, not the PCPs at the local HMO. Does she understand the "big idea" of chiropractic, or even the small idea of your office? Do your staff members know how to work as a team, or do you have each member pulling in her own load in different directions, albeit opposing others? Using Covey's analogy, has your staff synergized together, or are they still fighting among themselves?
Who determines your office culture of shared values? Have you, as the leader, established a mission statement? Have you shared with them your scope of practice or your philosophy of health? Furthermore, do you use mentors to help your staff up the professional learning curve? In my office, I have used audiocassette tapes for years to enlighten my staff to the higher consciousness of Peters, Gerber, Covey and others. It's amazing what can be learned from some of the best minds in business. Without this type of help, your office will remain at the bottom of the curve. All the while, you'll be wondering why!
One reason why the average DC has only one to two staff people is primarily the chiropractor's inability to manage, to empower and to lead their staff. It then becomes a matter of the blind leading the blind in this area of business acumen. Without leadership skills, most DCs are doomed from the start. As Stephen Covey wrote: "Effectively delegating to others is perhaps the single most powerful high-level activity there is." Regrettably, too few chiropractors are capable of delegating, thereby explaining why they cannot build a team of empowered, professional CAs, and they end up doing it alone and overworking themselves.
With these three concepts of management in mind, it becomes clear that your success has less to do with your clinical methods, your location, your free spinal exams and such as much as it has to do with these intangibles of success. If you want more success, I encourage you to study from experts the various management concepts and methods that have proven effective, namely, management values and total quality management. Forget about outdated concepts like management by statistics. Forget about an autocratic office where leadership is a function of who shouts the loudest. I suggest you listen to tapes by Peters, Covey, Gerber, Michael Vance, and Robert Schuller, to name but a few of the many mentors who have given us the gift of their knowledge on tape! The sooner you get up to the leadership/management learning curve, the sooner you might enjoy the success to which you are entitled!