Management Skills for Clinicians: Advancing Your Skills 1949991326, 9781949991321

Citation preview

Management Skills for Clinicians, Volume II

EBOOKS FOR BUSINESS STUDENTS

Linda R. LaGanga

POLICIES BUILT BY LIBRARIANS • Unlimited simultaneous usage • Unrestricted downloading and printing • Perpetual access for a one-time fee • No platform or maintenance fees • Free MARC records • No license to execute The Digital Libraries are a comprehensive, cost-effective way to deliver practical treatments of important business issues to every student and faculty member.

For further information, a

This book will be helpful in supporting those wanting to promote in the field. —Louise Delgado, LPC, CEO of Solvista Health I like the book using the numerous other authorities from which Linda has drawn . . . this book will become the ‘go-to’ source because with it you can find tons of resources if special attention is needed in one area. —Curtis Smith, Attorney, former board member of MHCD In this second volume for clinicians who have transitioned into administration, we continue the journey to advance management skills. Developing business skills in hiring, human resource management, and financial management will help garner and administer the resources that support a team’s important work. Readers will learn to embrace conflict and handle it constructively, as well as deepen skills for developing personal and team member strengths to enhance performance and sustain success as a health care manager. Linda R. LaGanga has 30 years of management experience. With a master’s degree in clinical mental health counseling, she worked directly with clients in community mental health. She applied her management and process improvement skills she had gained from her prior career in a startup computer software company, where she built the customer support organization and rose to senior management. She advanced to executive levels of management in healthcare organizations. Her PhD in operations research contributed new approaches to expanding access to healthcare services. She has published, taught classes, and conducted workshops in process improvement, clinical appointment scheduling, quality management, hiring and human resources, and mental health first aid. Linda helps organizations and people to discover their strengths and apply their resources to serve their customers and patients effectively.

free trial, or to order, contact:  [email protected] www.businessexpertpress.com/librarians

Healthcare Management Collection David Dilts and Lawrence Fredendall, Editors

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Curriculum-oriented, borndigital books for advanced business students, written by academic thought leaders who translate realworld business experience into course readings and reference materials for students expecting to tackle management and leadership challenges during their professional careers.

Advancing Your Skills

LAGANGA

THE BUSINESS EXPERT PRESS DIGITAL LIBRARIES

Healthcare Management Collection David Dilts and Lawrence Fredendall Editors

Management Skills for Clinicians, Volume II

Advancing Your Skills

Linda R. LaGanga

Management Skills for Clinicians, Volume II

Management Skills for Clinicians, Volume II Advancing Your Skills Linda R. LaGanga

Editors David Dilts Larry Fredendall

Management Skills for Clinicians, Volume II: Advancing Your Skills Copyright © Business Expert Press, LLC, 2019. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means— electronic, mechanical, photocopy, recording, or any other except for brief quotations, not to exceed 250 words, without the prior permission of the publisher. First published in 2019 by Business Expert Press, LLC 222 East 46th Street, New York, NY 10017 www.businessexpertpress.com ISBN-13: 978-1-94999-132-1 (paperback) ISBN-13: 978-1-94999-133-8 (e-book) Business Expert Press Health Care Management Collection Collection ISSN: 2333-8601 (print) Collection ISSN: 2333-861X (electronic) Cover and interior design by S4Carlisle Publishing Services Private Ltd., Chennai, India First edition: 2019 10 9 8 7 6 5 4 3 2 1 Printed in the United States of America.

Abstract Volume II helps readers advance their skills to thrive in administration. The focus is on enhancing relationships, your workplace culture, and your comfort with business practices for effective budgeting, financial management, hiring activities, and human resource management while building your momentum and growth. Advancing your communication skills will help you grow and improve as you foster the growth of those you manage and lead. You will learn to embrace conflict and handle it constructively. Developing your business skills in hiring, human resource management, and financial management will help you garner and administer the resources that support your team’s important work. Recognizing and developing the strengths of you and your team members strengthens performance and motivation to sustain your success as a health care manager.

Keywords management; hiring; business skills; budgeting; workplace culture; health care administration; strengths assessment; conflict management

Contents Preface...................................................................................................ix Acknowledgments................................................................................xxiii Chapter 1 Enhancing Your Relationships at Work: Managing Communication, Feedback, and Conflict...........................1 Chapter 2 Hiring and Engaging People in a Culture of Well-Being......27 Chapter 3 Business Basics: Finance and Budgeting Are Not Just for Accountants!...............................................................65 Chapter 4 Where Do You Go from Here? Keeping the Motivational Fire Burning..............................................103 Appendix A Grant Funding: Why or Why Not?................................129 Notes..................................................................................................131 References............................................................................................137 About the Author.................................................................................143 Index..................................................................................................145

Preface Continuing Your Journey, from Volume I to Volume II As a health care manager, you know there are many skills for you to learn and practice. These help you leverage your valuable clinical training and experience to maximize your effectiveness as a health care manager and administrator. These books focus on the management skills you are likely to need at appropriate points in your professional journey. Topics are ­organized into two volumes: • Management Skills for Clinicians, Volume I: Making the Transition from Patient Care to Health Care Administration • Management Skills for Clinicians, Volume II: Advancing Your Skills to Thrive in Administration In the first volume, Management Skills for Clinicians, Volume I: Making the Transition from Patient Care to Health Care Administration, we helped you shift your focus from working with individual patients to working within a system of care where you manage people and administer resources to serve your organization’s populations of patients. The chapters in that volume helped you understand the special features of managing in health care settings. You learned how to take charge to lead your team, manage the performance of those who report to you, involve others in planning, organize your activities, and influence others around you to collaborate with you. You gained skills to build relationships with the people you manage, such as your boss, and others around you. ­Volume I prepared you to manage in all directions. You learned to lead other professionals and administer many necessary activities that keep health care organizations running smoothly. Here in this second volume, Management Skills for Clinicians, Volume II: Advancing Your Skills to Thrive in Administration, we delve further into your growth and development in your management role. As you develop

x PREFACE

and gain experience as a manager, you will encounter continuing opportunities to advance the skills you worked on in the first volume and to learn new specific business skills we will cover now in this second one. Here you will learn more about enhancing your relationships along with building a positive workplace culture on your teams and more broadly throughout your organization. You will gain familiarity and comfort with business practices for effective budgeting, financial management, hiring activities, and human resource management while building your momentum and growth. Advancing your communication skills will help you grow and improve as you foster the growth of those you manage and lead. You will learn to embrace conflict and handle it constructively. Developing your business skills in hiring, human resource management, and financial management will help you garner and administer the resources that support your team’s important work. Recognizing and developing the strengths of you and your team members strengthens performance and motivation to sustain your success as a health care manager. More information is provided in the following text to help you navigate these books to provide timely help in your managerial journey. First, I would like to offer a view of where and how the material for these books developed.

Background from the Author As the author of these books and a health care manager myself, I have been there with you, experiencing joy and enrichment with new opportunities to develop mastery of skills that stretch our capabilities, and struggling with unexpected challenges revealed by new situations we had not yet experienced. Before writing these books, I worked for almost 30 years in progressive levels of management. After completing an advanced degree in a clinical field, I earned clinical credentials through testing and experience, made the transition from clinician to manager, and progressed to executive levels of leadership leading large departments in two large behavioral health centers. I am a Licensed Professional Counselor, National Certified Counselor, and certified Mental Health First Aid Instructor. Before becoming a

PREFACE xi

therapist, I was in high-technology settings and the computer software industry, where I worked my way from customer service and technical consultant positions to become a supervisor, then a manager, and continued to progress into senior and executive management. I have led clinical, technological, quality, customer service, and analytical operations. While experiencing the challenges of operating effective health care delivery with limited resources, I decided to update my skills to optimize the allocation of clinical resources. I returned to school and earned my PhD in Operations Research. My doctoral dissertation and research have concentrated on improving access to health care services. Many of the people I have worked with provided helpful leadership by example that inspired descriptions in this book. This book reflects valuable lessons from the Mental Health Center of Denver (MHCD), where we built the foundation for a thriving culture that promotes the well-being of its employees and clients. The mission of MHCD is “Enriching Lives and Minds by Focusing on Strengths and Well-Being,” founded on the philosophy that “people can, and do, recover from mental illness and that treatment works.”1 MHCD is focused on making a difference in the lives of tens of thousands of people every year, on mental health literacy inspiring people to become messengers to the larger community, and on expanding access to effective and compassionate treatment. MHCD has been named as a Top Workplace by the Denver Post for 6 years in a row, was honored as the Top Company in 2017 in Health Care by ColoradoBiz Magazine, has earned numerous awards for innovative projects that enhance the well-being of the community, and is recognized internationally for measuring and improving treatment outcomes. MHCD is where I experienced the initial transition in my career from clinician to manager—first, from providing direct clinical care, then to managing teams and staff, and later to higher levels of executive management responsibility. Lessons from this exemplary workplace, and interviews with many of my colleagues there, are included in this book. I gathered helpful input from many others, including my colleagues at Mental Health Partners (MHP). As a member of MHP’s executive management team, I participated in the development of its Mission, Visions, and Values: “In alignment with our mission—Healing is our purpose.

xii PREFACE

Help is our promise. Health is our passion. MHP provides immediate access to expert mental health and substance use care so people can enjoy healthy and fulfilling lives. Our vision is for Healthy minds. Healthy lives. Healthy communities. We accomplish this through our core values: Empathy: Putting ourselves in others’ shoes. Hope: Believing in positive possibilities for every person. Healing Environment: Providing a safe space where people feel accepted. Wellness: Supporting long-term health and well-being. Teamwork: Realizing the power of working together with humility and trust. Partnership: Building relationships to strengthen our communities. Excellence: Pursuing the best in everything we do.” MHP collaborates with many organizations throughout the community to deliver integrated and coordinated care, with work in shared locations with primary care physicians. An innovative comprehensive health home brings together treatment providers in one location for mental health, physical health, and dental services. “The health team works together to meet all of a patient’s needs and improve their overall health”2 MHP was one of four community mental health centers accepted into the Colorado State Innovation Model (SIM), a federally funded, governor’s office initiative that helps health care providers deliver whole-person care. According to Colorado Lieutenant Governor Donna Lynne, “SIM providers must focus on the entire patient, which means addressing mind, body and mental wellness. That complete approach to health is what makes the SIM initiative so valuable. Patients get the care they need when they need it, and providers learn how to succeed with new payment models. It’s a great example of meaningful reform in our state.”3 To broaden my perspective outside the settings where I have worked, I also spoke with nurses, MDs, and many professionals with experience in other health care systems and hospitals throughout the United States. Some of them I met through professional associations and applied research activities on improving health care systems. Together, many of us have collaborated in bringing effective management and leadership

PREFACE xiii

practices from prior work settings, then adapting them to fit new settings to enhance our work cultures and help our people develop. This is reflected in many of the examples you will see in this book. To help you in your development as a health care manager, chapters are developed around the skill areas identified by this book’s editors and author, from our experience in health care, as crucial to the success of health care managers. Successful health care leaders need a variety of skills to manage effectively in the complex and challenging arena of health care, where risks and rewards can have major impacts on the well-being and safety of our patients and care recipients. Such skills are described and illustrated with the actual experiences shared by many health care management professionals, along with recommendations from many management books and articles. Learning activities and discussion questions are offered in each chapter to help you assess your proficiency, apply new knowledge, and increase your mastery of the material. Personal skills and abilities are included to focus on how you relate to and communicate with other people, sometimes referred to as “soft” and “people skills” or with the ability to recognize and manage our emotions, as “emotional intelligence.”4 While some of the chapters focus on more “technical” or “nuts-and-bolts” skills such as hiring and budgeting, integrated throughout the book are the softer leadership skills that you need to successfully manage in these other areas.

Contents and Organization of Management Skills for Clinicians, Volumes I and II This two-volume set of books consists of: • Management Skills for Clinicians, Volume I: Making the Transition from Patient Care to Health Care Administration • Management Skills for Clinicians, Volume II: Advancing Your Skills to Thrive in Administration Volume I guides readers through the essential knowledge and understanding they need to develop as soon as they transition to new managerial roles. The emphasis is on shifting focus from caring for individual

xiv PREFACE

patients to taking broader responsibility for leading other professionals and administering the necessary activities that keep health care organizations running smoothly. The chapters focus on understanding the special features of managing in health care settings, taking charge to lead your team, managing performance of those who report to you, essential skills for planning and organizing, and building relationships with the people you manage, your boss, and others around you. Volume II helps readers advance their skills to thrive in administration. The focus is on enhancing relationships, your workplace culture, and your comfort with business practices for effective budgeting, financial management, hiring activities, and human resource management while building your momentum and growth. Advancing your communication skills will help you grow and improve as you foster the growth of those you manage and lead. You will learn to embrace conflict and handle it constructively. Developing your business skills in hiring, human resource management, and financial management will help you garner and administer the resources that support your team’s important work. Recognizing and developing the strengths of you and your team members strengthens performance and motivation to sustain your success as a health care manager. Objective We introduce new managers working in health care to the basic skills and competencies to support them in transitioning to their managerial roles. We guide readers in the activities they will handle initially and later as they arise in organizational cycles, such as budgeting and hiring. We also offer topics and examples that can help more experienced managers reassess and revitalize their skills. Target Audience We target clinical staff who have been promoted recently into managerial, supervisory positions. The targeted reader has clinical training and experience, and little or no business management training and experience. More experienced managers can benefit, too, from collected insights of other managers who were interviewed and from examples in recent and revisited literature.

PREFACE xv

How to Use These Books We cover both “hard” business skills and “soft” people/organizational skills. These books draw from books, articles, examples and managerial experience of the author and colleagues at different organizational levels and throughout health care settings and professions. As you see examples from health care managers who were interviewed for these books, consider how you could apply their approaches effectively to align with your strengths and the characteristics of the organization where you work. Tables developed in these books provide a foundation for you to develop tools tailored to what would work effectively in your environment. Review the frameworks described from other literature and practice applying them in your managerial and administrative activities. As you gain experience as a manager, experiment with what is offered and build your own tool sets to boost your effectiveness and to contribute to your organization. Health care management is complex with a wide range of interrelated activities that a manager will likely encounter, often in the same day or workweek. Volume I covers the things most needed from your first day as a new manager. You also may encounter other topics—such as hiring and budgeting, which are examined in Volume II–early in your new role. As your needs unfold in your management role, you may find it helpful to shift from reading sequentially the chapters in each volume to delving more deeply into specific chapters and sections that address the issues you are encountering.

Chapter Descriptions Volume I: Making the Transition from Patient Care to Health Care Administration Chapter 1. Introduction to Health Care Management This chapter introduces the unique challenges of new health care managers, explains their importance, and provides practical guidance to help you succeed in these new situations. Insights and themes from interviews and conversations with 64 health care managers and administrators are summarized. We identify some special features of managing in health care and the particular challenges in refocusing your clinical training to succeed as a health

xvi PREFACE

care manager as we apply some of the lessons gleaned from interviews. Initial activities are proposed to help you get started in comprehending the scope and skills that health care managers need to learn and master. Topics in This Chapter: • Motivation for developing management skills • What’s so special about health care management? • Interviews from a variety of perspectives • Interview questions • Themes from interviews • Who can help? Get a mentor! • Chapter summary and key points • Introductory activities to get you started Chapter 2. So, Now You Are in Charge! Leading Your Team and Managing When Others Report to You You are in a new role now with supervisory responsibilities. This requires you to transition from being a team member to the team’s leader. You need to establish credibility and earn the respect of others for new capabilities you are developing. You will need to treat others fairly and avoid granting special treatment to those who have been your friends. Mentors and peers can help you in your development so you do not have to figure things out all by yourself. We will show you how to communicate your expectations for behavior and performance to help your people perform well. We also look at what you need to do when things do not work out and improvement is needed, or you need to fire people who report to you. Topics in This Chapter: • What is different about being a manager • Delegating responsibility to others • Power and trust in your new managerial role • Setting expectations and communicating them • Accountability without fear and blame • Performance expectations

PREFACE xvii

• • • • •

Coaching for performance and development Performance tracking and planning Performance problems Chapter summary and key points Learning activities for this chapter

This chapter in Volume I focuses on how you get started in your new role with responsibility for managing others. Soon, you will develop more skills for creating a positive working culture, building a strengths-based team, selecting and hiring new people. Further information on these and other topics related to work culture, employee strengths, and hiring, are found in Volume II, Chapter 2. Chapter 3. Planning and Organizing You will face new challenges and be expected to make decisions in your role as a health care manager. Learning to lead with structure and applying some management tools can help you to take charge confidently as you plan, organize, and get things done. Topics in This Chapter • Planning and being proactive • Organizing and leading meetings • SBAR: a tool for effective meetings and other decision making • How decisions are made • Honoring your commitments for getting things done • Managing your time and yourself • Managing my time and myself: What I have learned and recommend • Chapter summary and key points • Learning activities for this chapter Chapter 4. Managing Up, Down, and All Around! Being a manager involves supervising and leading the team of people who report to you, and communicating clearly what you expect them to do.

xviii PREFACE

In Chapter 2, we looked at how you take charge and get started in that part of your role, and continued in Chapter 3 with structured techniques to help you plan and organize. Now, let us consider other important people in your new world of management. It is vitally important that you build a positive relationship with your boss and ensure you are meeting your boss’s needs and expectations of you. Those you work with as colleagues and peers also are important in your work world. We explore ways for you to build and sustain important relationships in multiple directions. You will gain wider perspective and effectiveness as you practice managing up, down, and all around! These are essential skills as you make the transition from providing direct patient care to managing the people and other resources involved in health care administration. Topics in This Chapter • Your new world and who is in it • Managing up: your important relationship with your boss • The importance of influence • Building positive relationships • Up, down, and all around for your successful transition to administration • Chapter summary and key points • Learning activities for this chapter

Volume II: Advancing Your Skills to Thrive in Administration Chapter 1. Enhancing Your Relationships at Work: Managing Communication, Feedback, and Conflict Your success as a manager requires that you build positive relationships. In Volume I, Chapter 4 titled “Managing Up, Down, and All Around!” we examined the essential relationships you need to establish with the people who report to you and with your boss whom you report to. We also looked at ways to connect with others in your organization to help you gain comfort in reaching out and building important relationship foundations. These topics helped build your

PREFACE xix

awareness and skills for managing up, down, and all around the organization you work in. Now it is time to enhance your relationships and work through some more advanced skills. It is natural that the various people you work with have different perspectives, so you can expect disagreements to arise. In this chapter, we extend your skills and effectiveness in communicating, giving and receiving feedback, and handling conflict. You will gain wider perspective and more experience as you practice building relationships and strengthening them all around you at work! Topics in This Chapter: • Reflecting on related topics in Volume I • Communication guidelines • Giving and getting feedback • Conflict in work relationships • Chapter summary and key points • Learning activities for this chapter Chapter 2. Hiring and Engaging People in a Culture of Well-Being Health care is all about people, who deliver treatment and keep the organization running effectively to meet the needs of the people we serve, our patients. In this chapter, we focus on these crucial human resources, the people who do the work on the team you manage. We will look at the value of creating a great place to work and the profile of a health care organization that built a work culture where people can thrive. Then, we examine the specific things you need to do to hire people and get them started in their work on your team. We will look at how you hire, engage, and retain these people to do their best work. We show you the value of your Human Resources team and identify the things they can help you with, and when you must consult with them to hire new people and bring them onboard. Topics in This Chapter • The importance of people! • What makes an organization a great place to work?

xx PREFACE

• • • • • • • • •

Using strengths in your team Your roadmap to hiring and human resources Hiring: Getting started Organizing your selection process Interviewing and selecting: What are you looking for and what should you ask? Compensation, terms, and job offers Welcome aboard and setting the tone Chapter summary and key points Learning activities for this chapter

Chapter 3. Business Basics: Finance and Budgeting Are Not Just for Accountants! Why do you need to know budgeting and finance? This chapter will answer this question by explaining some basic financial and budgeting concepts, why they are important for every manager to know, and how an effective manager uses these ideas. We will look at financial aspects of your organization that you need to know about to manage effectively. We start by reviewing why money is important to keep your organization and team running. We will explain budgeting and examine an example of a team budget to help you see what you need to track and manage. We will look at some financial measures for your organization and help you interpret them to understand the financial health of your organization. Topics in This Chapter: • Why money matters • Profit: What it means and why it is important, even in nonprofit organizations • Budgeting for what you are managing • Your budget: What does it look like and what does it tell you? • Big picture financial health of your organization • Recommendations for successful financial management • Applying financial principles in clinical practices • Chapter summary and key points • Learning activities for this chapter

PREFACE xxi

Chapter 4. Where Do You Go from Here? Keeping the Motivational Fire Burning In this final chapter, we wrap up your journey toward being an effective health care manager. We shift from the skills you have been learning in earlier chapters to do your job now, consider how you sustain your momentum, and look ahead to your future. We will look at how you balance areas of your life and renew yourself, sustain your success, address challenges that signal the need for changes, foster your growth and development, benefit from others helping you to improve, move from success to significance, and continue to fuel your passion for the work you do. Topics in This Chapter • Highlights of your journey to here • Leaders who are burning bright • Balance and renewal • Sustaining your success at work • Your growth and improvement • Outward and onward! • Chapter summary and key points • Learning activities for this chapter

Acknowledgments I am grateful to my family, friends, and many colleagues for your enthusiastic support, encouragement, and helpful suggestions along the way. I appreciate your patience and understanding as I dedicated my time and attention to writing this book. I am grateful to the editors of this Health Care series, David Dilts and Larry Fredendall, for approaching me with the idea of developing this book to fill a need you noticed in your work with health care organizations. Many thanks to you and publisher Scott Isenberg at Business Expert Press for your guidance, encouragement, feedback, and great suggestions that strengthened the usefulness of this book to the clinicians and managers we intend to reach. Thank you to Charlene Kronstedt for guidance on technical publication requirements. I appreciate many helpful conversations with Ginny Trierweiler, PhD, a licensed psychologist and professional coach who has helped many organizations and leaders to build their managerial effectiveness. In helping me conceptualize important areas to address in this book, she pointed out how power differences between managers and those they supervise can affect the transition for clinicians who are promoted to manage teams they worked in with former peers. I appreciate her wisdom about the clarity needed to transition from the role of individual clinician to manager and her suggestions for doing that successfully.5 Special thanks to Curtis V. Smith for volunteering to proofread and offering helpful writing suggestions. Thank you to the many professionals and organizations who generously shared their experiences with me in interviews and other conversations that helped to develop this book. They are all people whom I noticed and admire, or were referred by trusted colleagues, for their approaches, skills, experience, and contributions to the arena of health care management. Their insights and comments are included throughout the book. Everyone is listed in Appendix A of Volume I, along with selected highlights of interviews and conversations.

CHAPTER 1

Enhancing Your Relationships at Work: Managing Communication, Feedback, and Conflict Reflecting on Related Topics in Volume I Your success as a manager requires that you build positive relationships. In Volume I of this series, our chapter on “Managing Up, Down, and All Around!” examined the essential relationships you need to establish with the people who report to you and with your boss whom you report to. We also looked at ways to connect with others in your organization to help you gain comfort in reaching out and building important relationship foundations. These topics helped build your awareness and skills for managing up, down, and all around the organization you work in.

Chapter Overview Now it is time to enhance your relationships and work through some more advanced skills. It is natural that the various people you work with have different perspectives, so you can expect disagreements to arise. In this chapter, we extend your skills and effectiveness in communicating, giving and receiving feedback, and handling conflict. You will gain wider perspective and more experience as you practice building relationships and strengthening them all around you at work!

2

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Topics in this chapter: • Reflecting on related topics in Volume I • Communication guidelines • Giving and getting feedback • Conflict in work relationships • Chapter summary and key points • Learning activities for this chapter

Communication Guidelines Take initiative for communicating with others. This helps you build positive relationships, shows your loyalty to those you work with, demonstrates your capabilities for managing proactively, and often leads to better solutions and results.

Listening to Build Understanding and Open Dialogue Stephen Covey advises, “Seek first to understand, then to be understood.”1 Covey recommends listening with empathy to fully and deeply understand another person, the way she feels and sees the world. Good listening builds positive relationships and helps us avoid jumping to conclusions. Gene Dankbar of Mayo Clinic heightened his skills by taking classes in improvisational comedy, where there is practice in open communication by accepting and building on the ideas of others.2 With the approach known as, “Yes, And,” people learn to improvise by agreeing with the previous statement by someone else (with “Yes”), then building on that idea with something new (linking it with “And”). This promotes the flow of creativity and helps teams create more ideas, rather than shutting down contributions with a response such as “No, But.”3 When we say things like, “No, that won’t work here,” or, “But we already tried that and it didn’t work,” we communicate our resistance to other people’s ideas. Instead, try building your alignment with others by communicating your agreement or acknowledgement that their ideas have merit, and then add what you think could enhance it.



ENHANCING YOUR RELATIONSHIPS AT WORK

3

ABCs of Dialogue with Agree, Build, and Compare An option for building dialogue with others is the “ABC” approach of Patterson et al. (2012) to Agree, Build, and Compare. Start with Agreement Look for and start with the points of Agreement. If you completely agree with where another person is going, say so and move on. Agree and Build If you disagree with some of the points, then Agree and Build. Similar to the “Yes, And” approach, you could say, “Absolutely. In addition, I noticed that . . . ” to add the pieces that are important to you and missing from his position. Compare Then, rather than suggesting the other person is wrong, you could suggest where you differ by moving to Compare to describe how you see things differently and “invite the other person to help you compare it with his or her experience. Work together to explore and explain the differences.” This approach can help you avoid turning differences into arguments that interfere with healthy relationships and good results.4 Here are some illustrations of how this could work. Example 1 • Start with Agreement: “Absolutely, the new automated shift ­scheduling system made it much easier to plan for coverage over the holidays.” • Continue to Build: “In addition, I saw there were still some lastminute schedule adjustments.” • Next, Compare: “Did you see that, too? What do you think we could do to build some backup staffing plans now to cover unexpected changes quickly without disrupting the affected staff members?”

4

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Example 2 • Start with Agreement: “It sounds like our new on-site pharmacy is convenient for our patients and they report they get quick refills and good customer service.” • Continue to Build: “And the nurses on my team tell me they aren’t getting timely information when something changes.” • Next, Compare: “Do you know how the pharmacists on your team handle these changes and if they’ve had any problems communicating with nurses?” As you listen attentively, you can ask questions that help you understand other people’s perspectives and priorities as you build alignment with them. It goes a long way toward preventing some uncomfortable conflict, and can be useful in working constructively with it when it inevitably emerges. We consider conflict more deeply in the final section of this chapter. “Be Mindful of the Weight Your Words Carry” This advice from Chris Radigan, LCSW, considers how our words can set the tone for people’s reactions and acceptance of us and our plans. It is important to remember that different people interpret words differently, especially with e-mail and the interpreted tone of requests and questions, which might differ from what you intended. Some things are best communicated in person; it is helpful to explain changes, why they are happening, and to ask for feedback. When Chris was a new manager, this approach helped establish trust with his staff to enlist the buy-in and support of his team members.5 Written Communications If you do communicate via e-mail or written memos and reports, summarize succinctly in the subject or opening words the purpose of your communication and what, if any, action is needed from your boss or others. This helps bosses (and others in your communication loop) manage the information overload coming their way in many organizations, and to



ENHANCING YOUR RELATIONSHIPS AT WORK

5

understand clearly and appreciate the good work you are doing. Imagine how helpful this can be for you if your boss’s boss hears of a problem and asks your boss about it and your boss can confidently respond about the constructive and proactive activities you are already planning and leading. Be Alert to Communication Omissions Communicate with your peers and others in the organization about changes and activities that impact their work or lie within their areas of responsibility. Make sure you never make commitments to others or communicate decisions that were someone else’s responsibility to make or approve! Have you ever been in a situation where you found out something was decided or happening, and you did not know anything about it, even though it was something you had the authority to approve, veto, or reshape? Imagine how you would feel in your personal or family life if you were told you were going to be cooking dinner for your large extended family, whose members have a long list of dietary requirements and participants, you would never have agreed to do it, and perhaps you do not get along with that branch of the family! Or someone in your household or neighborhood informed you that you would be picking up all the local soccer team members after their practice, on the same afternoon you had committed to facilitating a training session for an organization you lead. Or what about those friends of yours, back in high school, who you discovered were planning a party at your house the weekend your parents were going away? It is lucky that you found out about it and curtailed that one before having to explain to your parents why there was something different about the house when they returned! Things like this happen at work, too. Maybe someone who reports to you executes a plan that should have had your support or approval but they failed to include you in the planning and communications. Suppose that plan or decision interferes with other activities in the organization, alienated your colleagues, and required you to intervene to fix the damage. Did that make you want to support the activity or decision that was dropped onto you, or the person who instigated the situation? Do not be that person to your boss or others!

6

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Situations like these often happen when people assume that others support their plans, but they do not take the time to check or have direct conversations with those who need to be involved. Being intentional in our communications cultivates more productive flows of information and mutually supportive relationships. Healthy Communication You may hear people referring to communication and power issues as merely “office politics” and not to be taken seriously. They may be confusing healthy awareness and communication with unhealthy indirect communication and gossip about other people who are not present, which, indeed, should be avoided. As career expert Dale Dauten (2011) explains bluntly in a column to a reader who wrote in for advice, I know there are people reading your remarks and getting huffy about “company politics.” One of the dumbest things I hear smart people say is, “I do good work, and that should be enough—I refuse to play politics.” Corporate politics is merely the art of getting things done by communicating with people in the most effective way, and that means using language that they understand and respond to. If you declare yourself to be “above office politics,” then you have declared you don’t really care about being effective and don’t deserve to be promoted.6 You, in contrast, have already demonstrated through your qualifications and successful work that you do deserve to be promoted, and now you are a manager! Keep in mind that while the label of politics may carry negative connotations, influencing others is a very real and necessary component of leading and managing at work. Practicing clear communication skills as we have discussed here will help you build the working relationships around you that help you increase your effectiveness in leading your team and influencing others to collaborate with you and support your goals. And, in addition to what you say and how you say it, it is important to consider channels of communication and making sure you include the right people—those who have a need to know, the authority to decide, or the expertise to implement decisions effectively.



ENHANCING YOUR RELATIONSHIPS AT WORK

7

Including Others: Who Else Needs to Know? At the Mental Health Center of Denver, we found it helpful to consider “Who Else Needs to Know?” People quickly adopted this as WENK soon after it was introduced to the organization by Mary Peelen, Director of Health Information Management Systems, from her earlier experience in a home health organization. The approach helped prevent problems by making sure all relevant information and requirements were identified and considered ahead of time. This approach improved teamwork, collaboration, communication, and project implementation throughout the organization. It was especially helpful when we were awarded funding through grants to start new clinical operations that required new tracking codes, clinical outcomes analysis, service delivery, quality monitoring, and reporting across multiple functions and departments. WENK can be implemented with a simple checklist and commitment throughout the organization to follow it. The example in Table 1.1 is about a new clinic funded by a community foundation to increase access to health care treatment for low-income preschool children. You could develop a checklist or adapt Table 1.1 for use in your organization. Table 1.1  Example application of “Who Else Needs to Know?” model Departments or teams that need to know

How to inform and include

Representative (Name or position)

Allocate and furnish space for new clinic

Facilities and Purchasing teams

Invite to Postgrant Award Meeting

Facilities director, Purchasing manager

Hire treatment staff with experience in early childhood care

Human resources recruiting team, Program managers in early childhood treatment teams

Initiate hiring requisition, Review and update job description for clinical providers

HR recruiter, Director of Children’s services or designee

Update electronic health and accounting systems

Accounting, Health Information Systems

Invite to next Post-grant Award Meeting, Log change request in Information Systems Support queue

Controller, Director of Health Information Systems, Help desk coordinator

Activities

8

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Breaking Down Silos and Barriers Several interview participants talked about “silos” and the importance of breaking them down. Picture silos as distinct towers or receptacles holding resources that remain separate and do not get mixed with those from other silos. Breaking down silos in organizations means working cooperatively across functional areas to share efforts and pool information and other resources for the greater good of the organization. It requires that we raise our vision beyond the confines of our individual goals and team responsibilities and consider the broader mission and vision of our organization. Breaking down barriers can start with communication and appreciation for the contributions of other people, especially in functional areas outside your own team or department. We saw in the preceding text how we could involve and include others in implementing changes by actively considering who else needs to know and inviting them to participate in planning. Many people who were interviewed for this series of books mentioned the importance of building relationships with people in other departments or functions in their organizations, especially in administrative areas such as human resources and accounting where their guidance and expertise is valuable and often necessary. We will offer more specific recommendations in the later chapters focused on those functions. Example 1: Working Across Internal Departments When I assumed responsibility for a team that produced reports of services that were paid for by county funds, it appeared that we were responding to frequent ad hoc requests for information. In the past, clinical managers had been responsible for handling the reports themselves, without a solid system of scheduling and technology to assist them. Because the responsibilities were distributed among so many different people, we lacked a coordinated schedule for when the reports were due and expected by our external customers. Then I discovered that our contracts manager in the Finance department had recently acquired a contract tracking system where due dates



ENHANCING YOUR RELATIONSHIPS AT WORK

9

were visible and responsibilities for reporting and delivering could be assigned and communicated to the right people. Now we had the tools, and even the analytical team members available, to handle this efficiently, which alleviated a reporting burden from the clinical managers who had been scrambling to work these administrative reporting tasks into their other responsibilities. We coordinated the right resources to establish a predictable schedule for when the reports were due and expected by our external contacts at the county. My analytical team members knew ahead of time what they were responsible for and could manage their work schedules and due dates. They began to communicate actively with external report recipients to clarify expectations and negotiate what they could deliver if there were special requests for customized reports. By planning, organizing, and communicating across teams and departments, we built more effective workflows and more satisfying and productive relationships with our internal colleagues and our external customers. Example 2: Cultivating External Relationships “Relationships and sponsorships matter a lot. I was loyal to the people I built relationships with. It’s important to be protective of them.” Jesús Sanchez, PhD, built and protected his external relationships throughout his career in clinical, management, and administrative roles. He fostered relationships with other units and organizations, and knew it was important to get along with the people whom he valued. He found that his relationships were helpful in getting the job done. For example, when he was an outpatient clinic manager, his positive and mutually helpful relationships with his counterparts in hospitals helped the patients they both served to access the right levels of care promptly and smoothly. He removed barriers for his team members by working with his hospital counterparts to obtain needed resources such as parking access so his clinicians could more easily do their work when they needed to visit the hospital to coordinate with staff there. He valued the help he got from his external working partners and preserved trust and

10

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

integrity in these relationships by making sure commitments he made to them were upheld by his organization.7 This required him to communicate actively within his organization about the importance of these external partners. He enlisted the support of others “up” and “all around” in his organization whose help he needed to fulfill commitments and support the people who reported to him. Example 3: Recognizing Cross-Functional Collaboration Kelly Phillips-Henry, CEO of Mental Health Partners, supported and communicated successes throughout her entire organization. She explained that in organizations that provide clinical services, administrative contributions might not always be as visible or celebrated as direct clinical activity, yet it is important for all staff members to recognize how the activities throughout all of the organization have value and support the organization’s work and mission.8 She recognized efforts from all parts of the organization, including the fee collection project led by an administrative director, by sending an e-mail message to all staff to praise the efforts of the leaders and everyone who had participated throughout the organization.9

Giving and Getting Feedback Feedback takes many forms. When it conveys recognition or praise, it can encourage more of a desired kind of behavior. On the other hand, it can let people know when they need to correct or change something. Let us start by looking at how you can give feedback positively. Providing Positive Feedback It is important that you offer positive feedback to the people who work with you. This helps you build positive relationships by showing others that you notice and appreciate their contributions and what they do well. This demonstrates your goodwill toward them and establishes mutual support and alliance. It is especially important that you provide positive feedback to the people who report to you because it reinforces to them



ENHANCING YOUR RELATIONSHIPS AT WORK

11

that they are on the right path in doing what you want them to do. This enhances their performance by making it likely that they will continue to do the right things to achieve the goals you desire. Motivation author Barbara Fielder (1996) suggests using a systematic approach to track and ensure that you are giving positive feedback regularly by putting 10 coins in a pocket to remind you to give someone positive feedback, praise, or recognition. Each time you do it, move one coin to the other pocket.10 I heard of a manager who was told he did not give enough recognition to those who reported to him. He established a daily goal to get all 10 coins moved to the other pocket by the end of the day. People noticed a difference and felt more motivated in their work with him. A colleague of mine, Bill Milnor at the Mental Health Center of Denver, was intentional in developing the habit of noticing what others were doing well and deliberately praising them. This earned him the reputation of being a supportive mentor to many emerging leaders who developed their skills and grew their managerial effectiveness through his feedback and guidance. This illustrates Ken Blanchard’s and Spencer Johnson’s recommendation for you to catch people “doing something right” and offer immediate and specific praise and encouragement, along with your positive feelings about their progress and contributions to the organization.11 Regardless of your method, the key point is to notice the positive things people do and express appreciation. This strengthens the performance of others along with your relationships with them. For Corrective Feedback, Start with Permission A good way to set the stage for giving and receiving feedback is to apply Harley’s (2013) recommendation that you ask permission at the start of your working relationships. Ask people to be honest, encourage them to tell you if they notice something you need to change or improve, and ask for their permission for you to tell them if you see something getting in the way of their success. Do not assume you are doing a good job because no one has told you that you are not. You need to take control, verify others’ perceptions, and let them know that you welcome their feedback. This is crucial to your success.12 Her approach is effective with your boss,

12

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

peers, and those who report to you. Because of your positional power as their manager, the people you supervise may be reluctant to tell you the truth, but understanding their perceptions helps you know what you should adjust or continue doing to be as effective as possible. I noticed that my colleague, Vicki Rodgers at Mental Health Partners, was straightforward and effective in using this approach. She explained that she had learned to do this in earlier settings and had talked with someone she had reported to about how to ask for feedback. She was comfortable asking people she worked with, “If you’re ever uncomfortable with me or something I’m doing, feel welcome to call me on it.” This allowed permission for someone who reported to her to tell her directly when they were in supervision that the person felt that Vicki, her supervisor, was distracted by other things, “I need your undivided attention.” This prompted Vicki to refocus her attention on her supervisee, which improved their interaction at that moment and in the future.13 Open Up to Receiving Feedback “The physics are clear: close down and get worse. Or, open up and get better.” According to Henry Cloud (2013), leaders are hungry for feedback. Getting feedback means opening up to take in new information, beyond your own perspective, about your performance and its effectiveness, along with suggestions for improving it. He advises that you look outside of yourself and even go outside your organization, as many of the managers interviewed for this book did to learn from others with different experience and other points of view. This can help you open up and be honest about your difficulties and vulnerabilities with independent and unbiased external colleagues with whom you can be mutually supportive in encouraging each other’s growth and development. Cloud recommends, “Get coaching, join a leadership group or forum, avail yourself of continuing education, attend a leadership conference, and so forth.”14 Ask with “Start, Stop, Continue” A simple and effective framework for getting feedback about your performance is the “Start, Stop, and Continue” approach. It can be posed as a



ENHANCING YOUR RELATIONSHIPS AT WORK

13

question to others as, “From what you experience in working with me, what should I start, stop, and continue to do?” I was reminded a few weeks ago that it also can be used to reinforce learning and assess progress of yourself or others in working toward goals. Jean Rosmarin, PhD, my co-facilitator for a Mental Health First Aid training class we conducted for our county sheriff’s department, asked participants at the end of the class, “From what we covered today in class, what will you start, stop, or continue to do to practice good self-care?” This helped participants consider what they had learned and express an intention to practice it, and it provided feedback to us as facilitators about what they took away from the training experience. It helped us gauge how effectively we had covered some of the topics, and helped us understand some differing perspectives among our audience.

Conflict in Work Relationships “Don’t take it personally if others don’t agree. Explain it and move forward.”15 This advice from Jeff Zayach, MS, Executive Director of Boulder County Public Health, reminds us that you must learn to be comfortable managing people who have different perspectives and be able to move forward even if not everyone agrees with your decisions. This requires recognizing conflict when it happens, responding to it promptly, and resolving it with your words and actions. Why and When Conflict Occurs Conflict is part of life. It reflects different perspectives, preferences, and priorities. People may disagree in their values and beliefs. They may have different interpretations of facts and other factors. It emerges with those who report to you, coworkers, and those at higher levels. Often people just want and believe different things. It could appear when others react to you in your new management role and as you assert new authority as you work with people with different perspectives, goals, and approaches. Sometimes people violate expected behaviors and communication channels, perhaps unintentionally. Understanding and setting expectations can help you avoid initiating unwanted conflict; see Volume I in this series for more help with this.16

14

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Conflict was mentioned by a number of our interviewees who had been selected for a new managerial role ahead of others who had been with the organization longer and had sought the promotion to a management position like the one you have now. Many said they had felt hesitant, uncomfortable, or unsure what to say or do to smooth things over and get people and relationships working well. In some cases, the new manager’s boss was helpful in supporting the new manager and not allowing others to ignore the new manager’s positional authority and exclude her from decision-making and communication channels. In other cases, the new manager’s boss was uncomfortable and avoided direct communications or actions that could ease the disruption of hurt feelings and nonproductive behavior of those who had not been chosen. If your boss is not actively reinforcing to others your new authority, you could try asking him directly for such support. However, if your boss is not willing or able to do this for you, you need to do it yourself. Conflict can be healthy when it occurs in an open and respectful environment where productive discussion can reveal new understanding between people who work together, or open up options and alternatives that lead to better decisions. However, it can be unhealthy and destructive when it remains unaddressed and festers bad feelings, people become entrenched in competing positions, believe they must exert power and control over others, or view discussions as win-or-lose games in which they must be the winner. Although it can feel threatening and tense, there are healthy ways we can work with conflict, which we should embrace rather than fear. You have already seen techniques in the preceding text, including “Agree, Build, and Compare” from Patterson et al. (2012) for listening and aligning with others to handle “crucial conversations.”17 Let us look at some additional ways to manage these crucial turning points and guide them to productive resolution. Embracing Conflict “Conflict can be welcome in helping to elicit and develop new ideas,” as Jackie Attlesey-Pries, MN, RN, observed.18 Stephen Robbins (2013)



ENHANCING YOUR RELATIONSHIPS AT WORK

15

explains that conflict can be constructive when it improves the quality of decisions by allowing various points of view to be heard, especially those that are unusual or held by the minority. This can help a group consider alternatives, challenge the status quo, and create new ideas. Groups composed of members with different interests tend to produce higher-quality solutions to a variety of problems than do homogeneous groups . . . Evidence demonstrates that cultural diversity among group and organization members can increase creativity, improve the quality of decisions, and facilitate change by enhancing member flexibility.19

“Now, Hear This with Love . . . ” People really enjoy working with Fred Michel, MD, a former teammate of mine, who recommends that we engage in conflict rather than avoid it. He suggests some approaches he uses successfully, such as a cue to ease into it without offense. For example, in team meetings, we recognized his opening of, “Now, hear this with love . . . ” and accepted willingly what followed because we trusted his integrity as he respectfully offered his opposing views or criticism of how things were working. In working with others such as the medical team members Dr. Michel manages, he sometimes starts with, “Good, bad, right, or wrong . . . ” to set the stage for the clear direction about “this is what we need to do.” He suggests aligning with others by starting with an apology to recognize something difficult or uncomfortable in their world before making a request. For example, consider starting with, “I’m sorry the weather is so cold when you had to come out here today for our team meeting.”20 This could be the preface for a request such as, “Now I need to ask for everyone’s cooperation in making sure our documentation is solid for the coming Medicare audit.”

Adapting Cues for You to Use How might you apply these suggestions in working through conflict situations or challenging requests you need to communicate? You could adapt

16

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

the cues to wording that is more natural for you. Here are a few examples for illustration: • “Now, I know this might sound far-fetched, but I wonder what would happen if we applied some tools from our technology team to remind ourselves to tell patients about our new clinic hours.” • “I’m listening to the ideas our team came up with, and I have to admit, I’m confused about what the goal is. Could someone explain how this helps our patients?” • “It’s difficult to comply with these new safety regulations, and I wouldn’t ask this if I thought we had a choice. Now, can we figure out how we’re going to put these in place by the federal deadline?” • “I’m sorry we’re all struggling with this new electronic health record. These transitions always seem to be difficult, and we have to do it because the old system is shutting down at the end of the month. Shawn, I saw you working with our vendor to pick up some helpful shortcuts. Are there some things the rest of us might learn to make it easier?” Conversation, not Confrontation “Start a conversation, not a confrontation,” Mark Murphy (2017) advises. He suggests asking the other person if she has time to talk with you, letting her know the topic, offering a few possible times and asking which would be convenient for her. This approach can be received by the other as more collaborative and less confrontational than a direct statement that you have a problem and want to talk to her about it.21 Imagine that it appears to you that a colleague has proceeded on his own in resolving a problem without considering your team’s responsibilities and the work your care team members already have in progress. Instead of expressing to him your feelings of frustration, you might approach him with a question to request time to talk about the situation, like this. “Marc, do you have some time to talk with me about our response to the Denton family’s complaint about their mother’s discharge? I’d like to coordinate with you on our communications.” If the other person agrees to talk, you can offer some times, such as, “Would you like to do it now or would it be better after lunch?”



ENHANCING YOUR RELATIONSHIPS AT WORK

17

If the other person wants to know more about why you want to talk, you might offer a brief, objective explanation, such as, “I want to make sure we’re in alignment on who’s handling which parts of the discharge process so we’re communicating clearly with the family and prevent confusion.” This opens the door to a nonjudgmental conversation that illuminates the activities that are occurring and who is handling them, which can lead to constructive and collaborative consideration of how things are working and what might be adjusted. With an approach like this, it is less likely the person will refuse to talk with you than if you had approached him more confrontationally, but if he does refuse, then Murphy recommends you respond with a question, such as “May I ask why?” to get more information about his perceptions. Discomfort with Conflict As Stone, Patton, and Heen (1999) point out, feelings matter, and they are often at the heart of difficult conversations. Unexpressed feelings make it difficult to listen to others, and take a toll on our self-esteem and relationships. People may dismiss their feelings as unimportant or unjustified, but your feelings are as important as the other person’s.22 As many experienced managers have shared, when they delayed talking to people about their concerns, they prolonged stress and discomfort in the relationships that they could have avoided by speaking up sooner. For example, a manager admitted that he delayed talking to someone who reported to him because he felt uncomfortable after she had overstepped her bounds by communicating to others a decision she made on his behalf without talking to him about it ahead of time. The manager had mixed feelings about the decision itself, and thought it might actually help the team function better, but he felt unpleasantly surprised and that his decision-making authority had been usurped. He avoided talking to the employee until several months later when he was annoyed with her about a different situation. When he finally blurted out his dissatisfaction about the earlier situation, she was astounded, and declared, “Why didn’t you just tell me? I don’t want my boss to be mad at me for all this time!” Why do we avoid these conversations? It may be a fear of offending or alienating the person, or opening up issues that you would rather avoid, such as your own inexperience or discomfort being in charge.

18

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

As Cloud (2010) points out, it is important to distinguish between the temporary “hurt” that can be a necessary part of providing uncomfortable feedback, and the longer-term “harm” to the organization caused by allowing performance problems to persist.23 The example illustrates additional principles to keep in mind as you begin to manage and lead others. Keep in mind that most employees really want to do a good job,24 and they want to please you as their boss.25 Think about feedback as an opportunity to coach employees so they can grow and develop. When you withhold your timely feedback, they are denied the information and opportunity they need to correct off-course behaviors and improve performance. They may unknowingly repeat things that hinder their effectiveness and annoy you, which detracts from overall team performance that you are responsible for. Think about how you claim your authority and leadership responsibilities as boundaries, in terms of what you expect, will accept and tolerate, along with limits that you will protect. Henry Cloud (2013) explains how this helps to position you to be an effective leader, or in his words, to be “ridiculously in charge”26 by establishing and reinforcing your position as the manager and leader of your team. Keep in mind that situations that trigger conflict can arise among people at different levels of hierarchy. It could be a peer-level colleague who says something in a meeting that you feel is unjustifiably critical toward you or your team. Or it might even be your boss who seems overly involved in making decisions about responsibilities she had delegated to you. In any case, do not delay. Open the conversation to share your observations, ask for feedback, and create understanding to prevent lingering problems and discomfort. Handle Conflict Promptly Be clear, direct, and prompt in addressing concerns, to prevent problems from lingering. If you believe that someone has crossed a line and behaved inappropriately in her role, or that his performance is not meeting standards and requirements of his job, or you have some team members who violate other expectations you hold for them, it is best for you to deal with such situations promptly. This helps you avoid more difficult



ENHANCING YOUR RELATIONSHIPS AT WORK

19

confrontations later, when they have assumed that you approved of their behavior or performance because you never told them otherwise! Initiate Needed Difficult Conversations You could initiate these discussions by calmly stating the facts along with what you noticed, and asking for the other person’s feedback. Mark M ­ urphy (2017) recommends a truth-based approach based on the facts of the situation.27 Let’s apply this approach to our example of the manager whose employee had communicated a decision without clearing it with him. Jane, I heard from several team members that you sent a memo announcing that I had decided that everyone could manage their own schedules and plan time off without prior approval from me as long as they found coverage for time when they planned to be away. I’m concerned because I was not aware that you were planning to announce a change, which I’m responsible for approving, about the way our team operates. Now several team members are confused and have asked for time in our team meeting agenda to clarify the procedure. These are the facts as the manager, Sam, is aware of them. Then he opens up the discussion by asking for the employee’s feedback. “Could we talk about what happened and how we could work together to plan and communicate effectively?” It is possible that the employee believes there are other relevant facts and perspectives to consider. For example, Sam, you said you spend too much time approving schedule changes. And you said you could use my help in finding ways to run things more efficiently. Other teams I’ve worked with operate this way and everyone likes it. I wasn’t trying to question your authority, I was trying to use my experience to help you and the team. Distinguish Blame from Contribution Stone, Patton, and Heen (1999) recommend that you distinguish blame from contribution. Blame is about judging, and looks backwards, in

20

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

contrast with contribution, which is about understanding and looking forward. Contribution is joint, interactive, and encourages learning and change.28 Jane had feedback for Sam about their working relationship and how to make it more positive and productive, and what she needed from him as the team’s manager. Let us consider how Sam might have contributed to the problem if he told Jane he wanted more help from her, but he was unavailable to talk to her about her suggestions. Suppose that he had denied Jane’s requests to meet with him and then overlooked an e-mail message Jane had sent him with a suggested plan, and Jane erroneously interpreted Sam’s lack of response as implicit support for her plan. Rather than looking backwards and blaming Jane for undermining his leadership and decision-making authority, Sam could look forward and talk to Jane about how she could offer her suggestions in helpful ways that he could understand clearly and respond to promptly. Such a conversation allows Sam to remind Jane of his willingness to listen to suggestions, and when and how to approach him with them, along with his expectations for approving decisions. Be Respectful toward the Other Person and Other Perspectives Sam demonstrated openness and respect for Jane and her perspective when he opened the conversation for her feedback. The dialogue allowed Jane to contribute her ideas, build more trust with Sam, and increase Sam’s comfort in delegating more responsibilities to her and other team members. This demonstrates that with openness to addressing conflict constructively, Sam and Jane each could benefit from the advice and encouragement found in Harley (2013) about “how to say anything to anyone,”29 especially when a team member needs to clear the air with a boss! Consider Role-Related Power and Authority Dynamics Remember, conflicts can and do occur up, down, and all around. The next time, it could be your boss who neglects to include you in needed



ENHANCING YOUR RELATIONSHIPS AT WORK

21

communication or decision making that encroaches on your responsibility and affects your team. Or it may be a coworker who seems to push for her goals to the detriment of yours. Be respectful and straightforward to initiate conversation, practice listening, and work toward understanding and alignment. Always be mindful of your position in the organizational hierarchy and be aware of who reports to whom. You do have power in your managerial role that gives you the authority to make many decisions and set direction for those who report to you.30 In turn, your boss has this authority over you. Adjust your approaches and conversations accordingly. You can be more directive with your employees than you can be with your boss. Consider appropriate approaches for you in your position relative to the other person’s. What should your stance be along a continuum from giving direction from a role of authority, to collaborating equally, to requesting direction from someone who has authority over you? For example, the other person made a decision, without your input, that affects your area of responsibility. Some more examples of responses with respect to relative roles of participants are provided in Table 1.2.

Table 1.2  Examples of responses with respect to relative roles of participants You and a You and an employee who coworker at reports to you your level “I’m concerned that you made a decision to change a process without my consent. Please don’t do that again, I need you to run operational changes by me for approval. How can we make sure that happens?”

“I heard that you told others that you’d decided to implement a new process. I have concerns because it affects my team’s work, too. Could we talk about it?”

You and your boss or higher level leader “I’m happy that you trust my abilities and asked me to take over the process change project. And I’m confused that you announced decisions you made that change the direction of the work I’d started on. Could we talk about how much responsibility you want me to take and what areas you prefer to handle yourself?”

22

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Guidelines for Handling Conflicts These guidelines (Table 1.3) summarize approaches we have covered for handling conflict. We apply them to an example situation of a manager who was unhappy with a coworker’s criticism of his team, which was discussed in a larger meeting with other coworkers and the senior manager they all report to. Table 1.3  Applying guidelines for handling conflicts Guideline

Application

1. R  ecognize when you feel your The manager feels taken off-guard, unjustly boundaries are violated or believe criticized, and unprepared to respond expectations were disregarded. constructively. 2. Consider the reporting hierarchy, your position relative to others in the conflict, and related dynamics of power and authority.

The manager and coworker are peers. Neither has formal reporting authority over the other. It is mutually beneficial for both to maintain a collaborative and supportive relationship with each other.

3. Resolve tension promptly and directly.

The manager could respond briefly and calmly in the meeting to say he was not aware of his coworker’s concern and would like to talk to her after the meeting to learn more.

4. Establish and refer to your The manager expects that coworkers will discuss expectations for communications directly with each other any performance and behavior. concerns rather than bring them up in larger meetings. He tells his coworker he wants to hear more about her concerns in a one-on-one conversation. 5. Stand up for yourself and assert yourself when needed to reinforce your authority.

The manager tells his coworker he is open to her suggestions on how to improve, and the final decisions on what to change are his responsibility. He accepts responsibility for his team and is confident in his ability to resolve any problems.

6. Initiate needed difficult conversations.

The manager should intentionally schedule a time with his coworker to have a conversation about his concerns with her criticizing him publicly and without fair warning, and to address the concerns she expressed.

7. Be respectful of the other person and other perspectives.

The manager should be open to hearing feedback, move from blame to considering shared goals and new options for achieving them. By asking questions, he can find out the source of his coworker’s dissatisfaction and how he and his team can resolve it.



ENHANCING YOUR RELATIONSHIPS AT WORK

23

Chapter Summary and Key Points In this chapter, we offered communication guidelines and recognized the ways feedback and conflict are important elements of the workplace. We suggested ways for you to give and receive feedback in constructive ways that foster relationships and help people work together collaboratively. We examined conflicts and offered guidelines for handling them in ways that build positive relationships and get work done effectively. Key Points: 1. In communicating, listen and seek to understand others. Consider your words and choose them to build alignment. 2. Be mindful of your words and tone in your spoken and written communications. Be clear and direct to ensure others understand accurately what you intend to communicate. 3. When you are involved in change, consider who else needs to know and include needed people early in planning activities and decisions. Use a checklist for who else needs to know and be alert to avoid leaving anyone out. 4. Sharing information and pooling resources among different parts of the organization can break down silos to foster cooperation that helps get things done more easily. 5. Positive feedback is important for showing appreciation and reinforcing positive actions that you want your team members to continue. 6. Ask for permission to give feedback to others and ask them to tell you if you need to change or improve something. 7. To gain precise, targeted feedback, ask others what they suggest you start, stop, and continue to do. 8. Conflict is inherent in the workplace because of the varying perspectives of different people. Learn to embrace conflict and manage it in healthy ways. 9. Understand your own boundaries that you need others to respect. Recognize when others violate them, and respond promptly and appropriately to others whether they are up, down, or beside you in the organizational hierarchy.

24

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

10. Be clear, prompt, and direct in handling conflict so that issues get resolved and relationships thrive. 11. Use conversation, not confrontation, to initiate constructive resolution of disagreements. 12. Recognize and respect the differences in positional power and authority of people in roles at various levels in relation to yours.

Learning Activities for This Chapter 1. Think of a problem that needs to be solved in your organization, which requires cooperation between you and a peer. Consider what points you both agree on, where your perspectives differ, and how you might agree to work together to solve the problem. Plan a conversation you could have using the framework of Patterson et al. (2012) that we reviewed in this chapter to Agree, Build, and Compare. 2. What projects or situations come up at work, which require careful consideration of “Who else needs to know?” Construct a table or checklist, like the example in Table 1.1, which would be helpful to use in your organization. 3. List three things you have noticed people doing well on your team in the past few days. a. Write down what you could say to those people to give them specific positive feedback that recognizes their good work and encourages them to continue to build on it. Now, go deliver the feedback. b. Look for at least three more opportunities in the coming week to offer positive feedback to others who work with you. 4. What will you say to others to encourage them to give you feedback about how well you are meeting their expectations and what you need to improve? 5. In this chapter, we introduced a framework for getting feedback by asking others what they would like you to Start, Stop, and Continue doing. You can also apply this for self-assessment and goal-setting for your professional development. From what you saw in this chapter, what will you Start, Stop, and Continue doing to become more effective?



ENHANCING YOUR RELATIONSHIPS AT WORK

25

Here’s an example to get you started. “I will • Start scheduling regular meetings with my boss to review goals and get her feedback on my progress. • Stop avoiding difficult conversations and believing that other people’s needs are more important than my own. • Continue to attend monthly skill-building seminars offered by my professional society’s local chapter to build my skills in managing others.” 6. Identify at least one work conflict or uncomfortable situation that you need to address. Imagine a conversation you could have to help resolve this and what you would say to get the conversation started. a. How would you approach the other person to start the conversation? Consider the other person’s role in the organizational ­hierarchy—in other words, are you peers at similar levels, or does one of you report to the other, or is one of you higher in the managerial hierarchy with more authority than the other? How do these relative positions of your role and the other person’s affect the way you approach the other person to start the conversation? b. Find an uninvolved person, not connected with the other person, who could help you practice this conversation by playing the role of the other person. What mentors or peers could help you with this? c. What feedback did you get from your mentor or peer-level buddy, or discover for yourself as you practiced, and what would you adjust in your approach to handling the conflict? 7. Think of a situation at work where someone’s actions violated your expectations for how he should have behaved. Work through Table 1.3 to apply the guidelines for handling conflicts, and fill in your application of each guideline. Refer to Table 1.2 for examples to help you apply Guideline #2 to consider the reporting hierarchy, your position relative to others in the conflict, and related dynamics of power and authority.

CHAPTER 2

Hiring and Engaging People in a Culture of Well-Being Chapter Overview Health care is all about people, who deliver treatment and keep the organization running effectively to meet the needs of the people we serve, our patients. In this chapter, we focus on these crucial human resources, the people who do the work on the team you manage. We will look at the value of creating a great place to work and the profile of a health care organization that built a work culture where people can thrive. Then, we examine the specific things you need to do to hire people and get them started in their work on your team. We will look at how you hire, engage, and retain these people to do their best work. We show you the value of your human resources team and identify the things they can help you with, and when you must consult with them to hire new people and bring them onboard. Topics in this chapter: • The importance of people! • What makes an organization a great place to work? • Using strengths in your team • Your roadmap to hiring and human resources • Hiring: getting started • Organizing your selection process • Interviewing and selecting: What are you looking for and what should you ask? • Compensation, terms, and job offers

28

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

• Welcome aboard and setting the tone • Chapter summary and key points • Learning activities for this chapter

The Importance of People! Health care is all about people—treatment and care keep people healthy and well, and these services are provided by people trained as health care professionals who work directly with patients; they also work with and are supported by other people involved in indirect services and processes that keep the organization running. According to many reports, labor represents about 50 percent to 60 percent of hospital costs and is the greatest driver of operating expenses.1,2 Costs and Consequences of Turnover Consider the consequences of losing people from your team, either due to ineffective selection or training or because they decide to leave and work elsewhere. Because of all the time we spend searching, selecting, hiring, training, and supervising employees, the costs of undesired turnover that occurs when they quit or need to be terminated are very high. Estimates of the cost of employee turnover vary widely because there is no standard methodology to calculate these costs. In several reports on general employee turnover across industries, the cost of replacing an employee is estimated to range from about 60 percent to over 200 percent of a person’s salary.3,4,5 There are some issues specific to health care, where salaries vary widely among health care professionals and specialties. There are costs of filling in labor gaps with high-cost temporary staffing to cover shifts—especially if you are working in facilities that provide 24-hour care—along with the decreased volume of revenue-producing activities that were being performed by trained and experienced people at high levels of productivity that new hires will not be able to reach without some time to learn and develop in their new roles. Michael Rosenbaum (2018) reports average turnover in health care jobs in 2017 was 20.6 percent, up from 15.6 percent in 2010, and the turnover rate for bedside RNs in 2016 was 14.6 percent. As he explains,



Hiring and Engaging People in a Culture of Well-Being

29

This is an expensive problem: A study in the Journal of Nursing Administration found that it may cost anywhere from $97,216 to $104,440 in today’s dollars to replace a nurse, including pre-hire recruitment and aspects such as unstaffed beds, overtime and losses in productivity.6 An earlier study by Waldman et al. (2004) estimates the total loss due to turnover as more than 5 percent of the total annual operating budget.7 If a 5-percent loss sounds insignificant, consider the magnitude of this loss if your organization’s annual operating budget is $10 million: turnover would cost the organization over half a million dollars! What about a $100-million annual budget, or higher: the estimated cost would be $5 million or more. That could pay for a lot of care and treatment for patients and benefits to your very valuable and important employees who deliver and support that care. Lower Turnover in Positive Workplace Cultures Author Brené Brown (2018) learned this in her leadership research: If we want people to fully show up, to bring their whole selves including their unarmored, whole hearts—so that we can innovate, solve problems, and serve people—we have to be vigilant about creating a culture in which people feel safe, seen, heard, and respected.8 The Great Place to Work organization surveys employees across industries to produce the annual FORTUNE 100 list of Best Companies to Work for in America and other Best Workplaces lists. From their 30 years of research, they conclude, “A Great Place to Work is one where employees trust the people they work for, have pride in the work they do, and enjoy the people they work with.”9 They define a “High-Trust Culture” as one where employees “believe leaders are credible (i.e., competent, communicative, honest), believe they are treated with respect as people and professionals, and believe the workplace is fundamentally fair.”10 A comparison of 2017 Best Place to Work data with industry data from the Bureau of Labor Statistics showed that voluntary turnover in the health care industry was only 8.8 percent in High-Trust Cultures, far lower than the rate of 21 percent for all health care organizations.11 High trust in the work culture is associated with additional positive results for organizations. A Great Place to Work study found that the

30

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

high-trust hospitals that made the 2016 FORTUNE 100 list of Best Companies to Work For had Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores significantly higher than the U.S. average for overall hospital rating and whether patients would recommend the hospital. “As patients are the ‘customer’ in a health care setting, these results demonstrate the positive impact a hightrust culture can have on the overall customer experience.”12 To understand more about great places to work in health care, let us look at the profile of an organization that intentionally focused on becoming one by engaging its employees and supporting their well-being.

What Makes an Organization a Great Place to Work? According to Carl Clark, MD, President and CEO of the Mental Health Center of Denver (MHCD), “It’s part of our strategic plan to create and maintain a Wellness Culture within the organization—a work environment where people can do what they do best and be supported.”13 “Wellness Culture” has shifted to “Well-being,” incorporating a holistic view of important areas of people’s lives as developed by Tom Rath (2010).14 The tenets of well-being have evolved and strengthen the organization’s enduring employee engagement.15 Recognition as a Top Work Place A powerful indication that employees agree is that at the time of this writing, the organization has been placed among the Denver Post’s Top Work Places for 6 years in a row, 2013 to 2018.16 The most recent announcement explained how, in describing their workplace culture, many of the employers participating in The Denver Post’s 2018 Top Workplaces described their commitment to diversity and inclusion. Employees at MHCD stated, “We value strengths, diversity and new ideas.”17 Results of the very competitive contest are determined by employee responses to 24 questions in these areas: 1. Alignment—where the company is headed, its values, cooperation 2. Effectiveness—doing things well, sharing different viewpoints, encouraging new ideas



Hiring and Engaging People in a Culture of Well-Being

31

3. Connection—employees feel appreciated, their work is meaningful 4. My manager—cares about concerns, helps learn and grow 5. Employee engagement—loyalty, motivation, and referral 6. Leader—confidence in company leadership 7. The basics—pay, benefits, flexibility18 Within these areas, employees are presented with questions framed as statements such as, “I believe the company is going in the right direction.” For each question, the employee selects his response from a 7-point Likert scale from “Strongly Disagree” to “Strongly Agree.”19 Training Launched Cultural Transition MHCD began to formally define its Wellness Culture in 2006, after our executive team, which I was working on, participated in a full week of ­engaging leadership training, at the suggestion of Joanie Gergen, our front office administrator at MHCD, who was offered a training class, “Pathways to Leadership,” free of charge by her friend at Verus Global. Throughout our journey to build a culture of wellness, the organization continued to measure and improve key indicators such as employee engagement and staff turnover. Before the training, the organization had several other activities in place that supported this snowballing effort. We were already offering employees the opportunity to assess their strengths, using the Clifton StrengthsFinder assessment,20 and applying Garold Markle’s (2000) Catalytic Coaching21 as a more engaging and empowering employee coaching and development approach that replaced older traditional performance evaluation systems. Beginning to Leverage Employee Strengths After the training, we extended the efforts throughout the organization. All new employees received Tom Rath’s StrengthsFinder (2007) book, took the StrengthsFinder Assessment and received personalized reports of their top five strengths, which they could share with their managers and others. For example, I learned that several of the people on my team were strong in “Deliberation,” which meant it was natural for them to think about the implications of new actions and initiatives before jumping into implementing them. So, as their manager, I learned that I could help

32

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

them move forward by encouraging them to apply their tendencies toward thorough evaluation to evaluate risks appropriately and recognize the value of avoiding undesired harmful outcomes. Another was strong in “Empathy,” so our team recognized his strength in being able to understand other people’s perspectives. We found it valuable to include him in planning in projects that would affect our consumers because he understood how they felt about the changes. We will look more closely in a later section at leveraging team members’ strengths for effective teamwork. Our employee coaching forms were updated to include and leverage each employee’s top five strengths. We measured engagement every year and our Board of Directors held our Executive Team accountable for attaining and sustaining high levels of engagement, as measured by employee survey results. Employee Engagement Initially, MHCD measured engagement with a survey we conducted internally based on 12 key questions formulated through extensive research and analysis by the Gallup Corporation, as explained in Marcus Buckingham and Curt Coffman’s (1999) book, First, Break All the Rules.22 This set of questions provides an excellent gauge for measuring the strength of a workplace and establishing a culture in which managers focus on what people do best to help them be most effective and engaged at work. The feedback from the surveys was reassuring, but after conducting it ourselves for several years with limited information about respondents and the groups they belonged to in the organization, we found it difficult to make meaningful change in some areas. Later we began to work with an external survey with added customized questions and specific tracking and analytical capabilities. The larger external analysis helped us to identify more specific driving actions that managers could apply in their own teams to continuously improve results. Jeff Tucker, JD, Vice President of human resources at MHCD, explained that in past years, around 2003, “The organization had turnover near 30 percent.” By 2014, already high engagement scores have continued to climb, turnover now hovers in the low teens, and more importantly, employees are improving their alignment with the organizational goals of expanding services, helping clients recover, and spreading mental wellness throughout our community.23



Hiring and Engaging People in a Culture of Well-Being

33

Defining the Culture Shortly after the leadership training in 2006, we engaged our managers in defining our Wellness Culture through an interactive process at an all-managers’ meeting, and all our managers agreed to the following tenets for “bringing out the best of ourselves and others:” 1. Seeing everyone’s strengths 2. Supporting and encouraging one another 3. Celebrating staff, accomplishments, and diversity 4. Respecting ourselves and others 5. Listening to each other 6. Creating an environment of healthy and positive relationships and community partnerships 7. Believing everyone wants to be great 8. Being passionate about our mission and having fun in the process 9. Believing anything is possible! Several themes are apparent in this collection of tenets. Notice the overall emphasis on strengths and possibilities, rather than on weaknesses and limitations. There is a strong emphasis on building positive relationships through listening, respecting ourselves and others, encouraging and bringing out the best in everyone. And the positive outlook with passion for the work we do and why we were doing it, with celebration and fun, certainly cultivated a sense of camaraderie and enjoyment that became apparent in the observable tone of the workplace. Outside visitors commented to our CEO that they were surprised by the laughter and smiling they observed, which was typically absent in earlier times and other settings where people did such challenging work for consumers with high needs and scarce resources available in the community to help. Impacting the People Served Roy Starks, MA, Vice President of Rehabilitation and Reaching Recovery at MHCD (2013), explains the significance of fostering a wellness culture for staff and its impact on the people served by those staff.

34

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

As with many community mental health providers, our initial focus was on the people we serve and how to help them achieve their life goals. Subsequently we began to more fully understand that our measures of recovery are really measures of human happiness and that, in short, consumer recovery is aligned with staff goals for happiness. This led to the understanding that the promotion of a wellness culture for staff is critical to the successful development of a recovery culture for the people we serve.24 As Roy explained when I met with him recently, this is a culture where the people working in it are making a difference, which shows up in meaningful outcomes that make a difference in consumers’ lives and saves money for society. It is important to bring it back to the mission.25 Meeting Needs and Realizing Dreams As Carl Clark, MD, explains, “Getting people what they need drives down costs.” This refers to both the people we serve, whose health and well-being improve when we help them meet basic needs first and curtails the need for higher-cost care and services later, and our employees whose engagement and retention drives down the cost of turnover. As for helping our employees get what they need, financial well-being needs to consider the different needs of five different generations in the workplace. New graduates are concerned with basic financial needs, are carrying a lot of student debt. The organization not only provides attractive pay and benefits, but helps employees learn to manage financially. This relates to understanding people’s dreams from a comprehensive view. As recommended by Matthew Kelly (2007)26 in his book, The Dream Manager, asking employees about their dreams, including those for their lives outside of work, can help you understand their motivations and increase their commitment and engagement with a workplace that helps them attain their dreams.27 Diversity and Inclusiveness Several years ago, the organization received feedback in a state-level quality review that we needed to strengthen our cultural competency efforts in treatment planning. The organization recognized an opportunity to go



Hiring and Engaging People in a Culture of Well-Being

35

above and beyond a compliance requirement by leveraging our wellness culture to elevate the engagement of our workforce. In 2014, through an extensive nationwide search, we hired an energetic expert in diversity and inclusiveness, Leslye Steptoe, PhD, to join our executive team. Her training and inclusion initiatives quickly had an impact in further engaging our existing employees and attracting many new ones that enriched the multicultural fabric of our workforce. Pillars of This Great Place to Work The main elements that support a great place to work for this organization can be depicted in this model, “Implementing and Sustaining a Great Place to Work,” as shown here and illustrated in Figure 2.1:28 1. Employee Strengths: The strengths-based approach that starts with each employee assessing his strengths and working with his manager on how to build and apply them at work. 2. Putting Strengths to Work: Incorporating strengths into coaching and dialogue between each employee and her manager based on Markle’s (2000) Catalytic Coaching process.

What are each person’s natural strengths? Strengths Finder

Putting everyone’s strengths to work: Catalytic Coaching

Engaging Everyone!

Best!

Measuring Results: *Staff Engagement and Drivers *Consumer Metrics

Figure 2.1  Implementing and sustaining a great place to work

36

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

3. Engaging Everyone: Measuring employee engagement to identify drivers of engagement and providing actionable results to managers and their teams to increase engagement. 4. Measuring Results: The organization measures engagement of its employees and the people it serves. a. Employee engagement surveys identify drivers of engagement and provide actionable results to managers and their teams to increase engagement and organizational effectiveness. b. The organization measures treatment outcomes as consumers’ progress in observable areas of their lives that reflect their recovery and through surveys of consumers about their own perceptions and feelings in areas that affect their progress. We have seen in this section the philosophies (beliefs) and practices (behavior) that drove this organization to catapult its organizational culture from being better to being recognized as one of the best. Unifying Themes In this section about what makes an organization great, we have presented several different models and components that contribute to employee engagement and organizational greatness. Let us compare these different models and structures side by side, as shown in Table 2.1. Although these are different models with different components, measurement scales, and purposes, they emphasize several common things in the components and purpose: 1. Strengths, growth and development of employees 2. Alignment, employees believing in the value of the organization’s mission and purpose 3. Organizational effectiveness, quality work, and results 4. Appreciation, recognition, and feedback 5. Participation as demonstrated in the contents, development, and ­application of the models.





37

Top work places

7 areas of the Denver Post contest using the Energage Survey.a The purpose is competition and comparison with other organizations, and identification of internal drivers for organizational performance improvement.

Model

Description and purpose

The 12 questions that “measure the core elements needed to attract, focus, and keep the most talented employees”b and the “camps” that show how employees evolve as they climb the “mountain” of engagement.c Internal measure of organizational performance in engaging employees, providing feedback and identifying opportunities for improvement.

Gallup Q12

Table 2.1  Models of employee engagement and organizational greatness

Defined by all managers to launch and promote the development of the organization’s foundational Wellness Culture. The tenets served as focal points to encourage and reinforce team and individual behaviors that contributed to the Wellness Culture.

(Continued )

A visual model created by this book’s author for internal strengths training and external informational presentations on MHCD’s approach to engaging and developing employees and the consumers served by the organization

Wellness Culture defined Implementing and by the Mental Health sustaining a Great Center of Denver Place to Work

38

Alignment—where the company is headed, its values, cooperation Effectiveness—doing things well, sharing different viewpoints, encouraging new ideas Connection— employees feel appreciated, their work is meaningful My manager—cares about concerns, helps learn and grow Employee engagement—loyalty, motivation and referral Leader—confidence in company leadership The basics—pay, benefits, flexibility

Components

Base Camp: “What do I get?” 1. Do I know what is expected of me at work? 2. Do I have the materials and equipment I need to do my work right? Camp 1: “What do I give?” 3. At work, do I have the opportunity to do what I do best every day? 4. In the last 7 days, have I received recognition or praise for doing good work? 5. Does my supervisor, or someone at work, seem to care about me as a person? 6. Is there someone at work who encourages my development? Camp 2: “Do I belong here?” 7. At work, do my opinions seem to count? 8. Does the mission/purpose of my company make me feel my job is important?? 9. Are my coworkers committed to doing quality work? 10. Do I have a best friend at work? Camp 3: “How can we all grow?” 11. In the last 6 months, has someone at work talked to me about my progress? 12. This last year, have I had opportunities at work to learn and grow?

Gallup Q12 Seeing everyone’s strengths Supporting and encouraging one another Celebrating staff, accomplishments, and diversity Respecting ourselves and others Listening to each other Creating an environment of healthy and positive relationships and community partnerships Believing everyone wants to be great Being passionate about our mission and having fun in the process Believing anything is possible!

Identifying everyone’s strengths Putting Strengths to Work Engaging everyone Measuring results: internal (employee engagement) and external (consumer progress in recovery)

Wellness Culture defined Implementing and by the Mental Health sustaining a Great Center of Denver Place to Work

The Denver Post. “Denver Post’s seventh-annual Top Workplaces contest begins.” https://www.denverpost.com/2017/09/10/denver-post-top-workplaces-contest-2018, (accessed December 29, 2017). b M. Buckingham and C. Coffman. 1999. First Break All the Rules. New York, NY: Gallup Press, p. 28. c M. Buckingham and C. Coffman. 1999. First Break All the Rules. New York, NY: Gallup Press, pp. 42–45.

a

Top work places

Model

Table 2.1  (Continued)



Hiring and Engaging People in a Culture of Well-Being

39

Next, we will take a closer look at what you can do yourself with the team that reports to you to leverage the strengths of your team members and increase their engagement.

Using Strengths in Your Team Assessment Approaches There are many different assessments used by organizations to determine styles and preferences of members of teams. Some mentioned by interviewees, among many instruments available, include MyersBriggs Type Indicator, DiSC, Clifton StrengthsFinder, Kolb Learning Styles, and Emergenetics. As Carl Clark, MD, says, “The better you know yourself, the better you know what you need on your team.”29 Everyone has different preferred approaches, styles, and perspectives, and teams work most effectively when we recognize and utilize people’s differences. Some assessment approaches include exercises and activities in which each team member participates in an assessment and receives a report or inventory of results, then the team works on solving a problem together. Usually this provides insights such as one I remember from an earlier setting where our team discovered that our most decisive and forceful members initiated action and got other members to follow, but without the ideas and recommendations of the quieter and analytical members, the team headed off in an unproductive direction, and missed opportunities to pursue more fruitful paths to effective solutions. Strengths-Based Leadership More recently on my teams, we have used the approaches in Tom Rath and Barry Conchie’s book, Strengths Based Leadership.30 First, each team member completes a StrengthsFinder assessment of 34 possible themes to find out which are his top five themes. These top five themes are the things we gravitate toward naturally because we have focused on them throughout our lives. When we continue to utilize these themes, they

40

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

become our strengths that help us perform effectively as we are doing what comes naturally. We feel more satisfied because our energy is directed more easily and we eliminate the struggles of trying to be what we are not. In the book, First Break All the Rules, Marcus Buckingham and Curt Coffman describe this approach as helping employees be more of who they already are.31 Doesn’t that sound smoother and more natural than trying to fix people? The Strengths-Based Leadership approach distributes all 34 of the themes into four domains: • • • •

Executing Influencing Relationship Building Strategic Thinking

Within your team, you can organize all of your team members’ themes, including yours, into these domains, as shown in this example in Table 2.2. Table 2.2  Example of team strengths by domain Team Member Executing

Relationship Influencing Building

Strategic Thinking

Kyle

Achiever

Maximizer

Strategic, Learner, Ideation

Sandy

Responsibility, Arranger

Relator, Individualization

Learner

Mike

Deliberative

Connectedness

Learner, Intellection, Input

Kim

Deliberative

Individualization, Connectedness, Developer

Intellection

Susan

Achiever

Connectedness, Relator

Strategic

Jerry

Connectedness

Learner, Analytical, Ideation, Intellection

Sam

Empathy, Positivity, Adaptability, Developer

Context

Bob

Maximizer

Maximizer

Ideation, Strategic, Learner, Futuristic



Hiring and Engaging People in a Culture of Well-Being

41

Discussion of this Team’s Strengths by Domain This team was strong in the Strategic Thinking and Relationship Building themes, with much collective strength that involved analyzing, planning, relating to, and listening to others. Some collective strengths involved getting things done, and there was relatively little strength as a team in influencing others. This was not surprising, as this team’s function in the organization was largely strategic and analytical. They worked well with others, collaborated with other teams, and sometimes felt frustrated with the time and effort they spent in cajoling and overaccommodating the needs of other teams at the expense of achieving their own goals as a team. The team discussed this honestly and agreed to use its collective strengths in Relationship Building by utilizing the team members who were strongly oriented to this domain to build relationships with others in the teams they needed to influence to help this team reach its project goals. They used some of their strengths in idea-generation and planning to brainstorm about how they would approach other teams; then they developed a schedule for ongoing visits to the other teams to enlist their cooperation. This strengthened collaboration with other teams and helped achieve better results and more timely completion of this team’s project goals. Strengths-Based Employee Development This approach can also be useful in your ongoing coaching and development with your employees. First, you get a better understanding of your own style and strengths and how you can use them to lead effectively. Second, you learn more about each of your employees and what they need from you based on their top themes that emerge. And third, you can help people identify others to work with who might help them complete an effective set of collective strengths. For example, an employee who gravitates toward generating ideas and building relationships but is not oriented toward planning and completing projects might benefit from using her relationship strengths to find someone to team up with who can help her bring her ideas to fruition.

42

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Strengths-Based Teams A key philosophy in this approach is that individuals do not have to be well-rounded, rather, focus on how to round out your teams. In other words, appreciate your employees for who they are and what they do well, and do not try to force them to be different. At the team level, look for ways to fill in areas where your team does not have collective strengths. Help to identify people, systems, and approaches that can help the team to be effective. And when it is time to hire some new team members, you might want to consider actively seeking people who are strong in areas that would round out your team. In later sections on hiring, we will see how you learn how people have applied what they do best in past situations so you can enlist them to enhance your overall team capabilities. We will also examine more closely how you can coach and develop your employees.

Your Roadmap to Hiring and Human Resources For the basic process for attracting and developing the people you need to keep on your team, follow these steps, which we will explain further in later sections. You may use this roadmap as a checklist to make sure you have covered the necessary steps. 1. Develop positive working relationships with all of your current team members. a. Concentrate on taking charge and managing effectively, building relationships, and communicating. For help, see Volume I ­(LaGanga, 2019), particularly Chapters 2 and 4.32 b. Build a positive culture on your team by applying principles like those described in our earlier section, “What Makes an Organization a Great Place to Work?” developed by a Top Work Place winner, as profiled in that section. c. Identify and focus on the strengths of your team members as described in the earlier section, “Using Strengths in Your Team.” 2. Evaluate hiring needs as positions are vacated. a. Communicate with your boss for input and to keep her in the loop. b. Proceed to Hiring when appropriate.



Hiring and Engaging People in a Culture of Well-Being

43

3. Hiring a. Contact your human resources department and follow procedures to register a current employee’s intention to terminate, then open the position for rehiring. b. Review the current job description, adjust as needed. c. HR posts and advertises the position through recruiting channels. d. Disseminate the position description and posting to people in your network of contacts and other hiring pipelines to encourage suitable candidates to apply. e. Review applications with HR as received, or in batches to compare and select. f. Screen applicants for their match with required qualifications (HR and you as hiring manager). g. Organize an interview team and Round 1 of interviews. i. Select an interview team (roughly three to eight people, teammates and representatives of related teams). ii. Schedule hour-long interviews followed by debriefing times afterward and another time to select finalists. h. Develop behavioral interview questions to assess job candidates’ abilities to handle the job and work productively on the team. i. Request input on questions from the interview team. ii. Collect and consolidate into interview questions (no more than 12, and allow time at the end for the candidate to ask questions). i. Conduct interviews using the same set of questions for every candidate (to allow objective comparison); complete scoring sheets (developed by you or HR). j. Meet with your interview team to evaluate Round 1 interview results and select finalists (two to three) to present to the interview team for Round 2 for further skills demonstration (if relevant) or to your boss or other final selection team. k. Round 2: Invite finalists to demonstrate key job skills (such as treatment planning with a patient, conducting a training session, or presenting on a relevant topic.) l. Meet with your interview team to select the final candidate to offer the job to, rank order candidates, and determine whether

44

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

alternatives would be acceptable if your first-choice candidate declines. m. Communicate with first-choice candidate (and other serious contenders) to confirm their interest and keep them engaged with you and your team. n. Conduct reference checks (HR department or you) and background checks with verification of licenses, credentials, criminal/ fraud checks as appropriate for the position (HR). o. Determine salary and terms of offer with HR for your selected candidate. p. Work with HR to present offer and discuss terms and start date (you or HR, depending on the standard hiring practices in your organization). q. Finalize offer and start date, send confirmation to your new hire! 4. Prepare for employee arrival a. Notify other departments who need to enroll the new employee in electronic systems for name badges, facility access, computer access and usernames, and to prepare work space and equipment. b. Enroll the new employee in needed training for computer systems, electronic health records, policies and procedures as soon as available after the employee’s arrival. 5. Onboarding and startup: New employee arrives! a. HR introduction to necessary payroll processing and paperwork. b. Organization’s new employee orientation to procedures and culture. c. Welcome lunch with new employee (you, one-on-one, or according to your organization’s practices which might be a collective event for all new hires together). d. Introduce employee to workspace, team members, other staff, and tour relevant parts of the facility. e. Assign a teammate to help and support the employee, arrange job shadowing as appropriate. f. Schedule and communicate times with employee for supervision meetings with you, other meetings with your teams, and other standard meetings.



Hiring and Engaging People in a Culture of Well-Being

45

6. Ongoing engagement a. Meet regularly with your employees to ask how they are doing, help them get questions answered or obtain needed tools and supports, talk about their goals and progress. b. Provide feedback, share observations with praise on successes, and guidance where improvement is needed. c. Continuing coaching and development. We will discuss more below!

Hiring: Getting Started Let us look at what we need to do to manage our human resources effectively, to select and develop the right people for our teams to help ensure we do not lose them unnecessarily. Effective hiring is an important first step. As Darcy Jaffe, MN, FACHE, Chief Nursing Officer at Harborview Medical Center, commented, “If we do make mistakes in hiring, people don’t stay.”33 She and others help us avoid those mistakes as they offer suggestions for developing and engaging our employees. Develop Positive Working Relationships In earlier chapters, both in Volume I and in this volume, we looked at how to build effective working relationships with the people who were already on your team when you started in your management role. We saw that there could be some particular challenges because you did not choose these people to join your team and report to you, and quite possibly, they did not choose you, either! Yet, you learned what to say and how to get along and lead with the people you had, who could be very helpful assets because they already knew how to do their jobs, get things done by following the processes and guidelines within the organization, and work effectively with others on your team and throughout the organization. Your positive working relationships foster a team environment that is helpful in retaining your current team members and attracting new ones for positions that open.

46

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Positions Open Up Now, as a manager, there will come a time when positions open up on your team and you will find and select new team members to fill them. These openings, also known as vacancies, occur because someone leaves, or there is growth that requires additional staffing in the form of new or additional positions, or there is some organizational restructuring and you inherit some vacant positions from another part of the organization. Let us start with the most straightforward of these, when an existing staff member leaves, perhaps because he is promoted out of his current role, or transfers to another position in the organization, or leaves the organization to move away, join another organization, return to school, retire, and so forth. Where do you begin? Communicate and Evaluate Rehiring Needs When someone turns in her resignation or communicates to you her intention to vacate her position, it is a good idea to let your boss know, along with your thoughts on how to manage the change and fill the vacancy. This is part of the expected practices of courteous and proactive communication that we discussed in earlier chapters, particularly in Volume I, on managing up and building a productive relationship with your boss. It is also an opportunity to demonstrate your initiative in planning proactively, as you may have some ideas on how to rearrange work or eliminate unnecessary steps, so you might be able to delay refilling the vacancy right away to save the organization some expense. Or you may already know of potential candidates who have expressed interest and would be valuable additions to your team. Contact Human Resources Your human resources department has established procedures for handling terminations and for proceeding to fill those vacant positions. So, you will need to contact HR to ensure you follow their requirements for processing the termination or transfer of the incumbent employee and opening up the position to be filled. The process might include getting a formal letter or e-mail from the departing employee to document his



Hiring and Engaging People in a Culture of Well-Being

47

resignation and the date he intends to vacate the position. You may request reasonable notice, usually at least 2 weeks. Some employees will be willing to stay longer to help finish open work with patients and transition responsibilities to other team members or a new employee. This is where it is helpful to have positive and mutually supportive relationships with the people who report to you, so they want to continue to support the good work of the team they are transitioning out of. If she is moving to another position within the organization, consider negotiating with the employee and her new manager to be able to extend her transition time or borrow some time after the transition for her to consult and help train her replacement. Evaluate and Plan for Refilling Next, when the position is officially being vacated through the proper notice and documentation, you may proceed to get the necessary approvals to open the position to refill it. Sometimes, especially if budgets are tight, organizations require a review of vacant positions to make sure they really do need to be refilled at the same level and salary range. When there are projected budget shortfalls, due to revenue shortages or higher-than-expected expenses, positions may be frozen temporarily or consolidated with other positions to reduce headcount as part of streamlining organizational operations to boost efficiency and manage costs. Messmer et al. (2008) recommend that you assess your staffing needs in terms of your department’s priorities. Consider whether you need to rehire or could reposition staff and duties to fill gaps.34 Review the Job Description In any case, you need the approval of the HR department to open the position for refilling and to post the job, which means announcing it and advertising it to attract applications. Be sure to review the job description for accuracy and to determine if any of the requirements or desired qualifications have changed. For example, are there any special skills or certifications required by new grants or funding requirements? Have any regulations changed or relaxed that can either restrict or expand the range of qualifications?

48

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Messmer et al. (2008) recommend that you be specific about the tasks the employee will perform and differentiate those from qualifications, which are the skills, attributes, and credentials required. Be clear about degrees and licenses that are required to do the job. Remember to consider the soft skills, such as communication and teamwork, which are important for an employee to work successfully in the position.35 Begin Recruiting with Posting, Advertising, Dissemination Double-check with HR and others to ensure that the job description and announcement are clear and accurate; this will save time later having to screen out unqualified applicants or having to re-announce the position because it did not attract enough qualified candidates who would be valuable assets working on your team. Now you are ready for HR to post the job through its recruiting channels such as hiring websites, your company web pages on hiring and open positions, and the trade organizations and professional associations that the organization belongs to and works closely with. You may distribute the announcement directly to your professional contacts and post to professional groups such as your alumni association and professional societies related to the disciplines and training of the candidates you seek. As Messmer et al. (2008) remind us, there are benefits in filling jobs from within the organization; this can reduce turnaround time and cost of filling the position, boost employee morale, and enhance productivity with employees who are already familiar with the organization. But do not limit yourself to internal candidates. External recruiting is valuable in broadening the selection of talent, opening up to fresh perspective and new ideas, and increasing workforce diversity.36

Organizing Your Selection Process Fairness and Employment Laws To ensure fair access and opportunities for employment for qualified applicants interested in a position, it is important to follow consistent steps and content to assess applicants for the position. Be aware of the



Hiring and Engaging People in a Culture of Well-Being

49

employment laws that apply to the country and location where you work. In the United States, for instance, the Equal Employment Opportunity Commission (EEOC) enforces federal laws that prohibit discriminating against a job applicant or employee because of the person’s race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age (40 or older), disability, or genetic information. The laws apply to hiring, firing, promotions, harassment, training, wages, and benefits.37 Be aware of additional laws that protect people with disabilities from discrimination and exclusion from employment in which they are able to perform the essential functions of the job, with or without reasonable accommodations from an employer. According to the laws of the Americans with Disabilities Act (ADA), “If an employer has prepared a written description before advertising or interviewing applicants for the job, this description shall be considered evidence of the essential functions of the job.”38 Keep in mind these requirements when you conduct your selection process and pose questions to candidates. This is another reason to work closely with your HR department whose members are familiar with the laws and requirements and know how to make sure the essential functions are justifiably required for the job and clearly included in position descriptions. Also, they can help you determine what reasonable accommodations may be appropriate for candidates or employees with disabilities. Focus on the requirements of the job and make sure you can explain how your assessments and questions relate to those requirements. You should never ask applicants about any of the characteristics listed above with EEOC; to do so could leave you open to complaints of illegal employment discrimination. For example, you may not ask candidates their age, whether they plan to become pregnant, which religious practices they follow, whether they have disabilities, or other questions targeted to identify their membership in groups or characteristics protected from illegal discrimination. Instead, you should stick to the requirements of the position, clearly communicate about key aspects such as the work schedule and any expected conditions such as long shifts and required overtime, and ask candidates if they can work with those conditions.

50

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Review Applications and Conduct Screening In your next step, you will review applications and resumes to determine which applications and candidates appear to be best suited to the requirements of the position and work setting. Your HR department will help and might perform initial phone screening interviews for you. The initial screening should verify that candidates acknowledge having the necessary qualifications including professional degrees, licensure, training and certifications, skills, and experience, and that their salary expectations fit within the range for the position. Later, for candidates who are finalists or selected for hiring into the position, background checks and other evidence will be obtained to confirm that the credentials are valid and current, with no disqualifying events or exclusions from state or federal payor sources and regulatory groups. You may conduct further screening interviews or individual meetings yourself to do deeper assessments of applicants’ qualifications for the position along with their motivations and suitability for working in your organization on your team and reporting to you. You are selecting and narrowing the set of those you will present to an interview team for deeper assessment of work styles, attitudes, some specific skills and capabilities, and compatibility with the organization and team. Organize Your Interview Team and Questions In the meantime, you can be assembling an interview team to represent your team and other relevant areas of the organization where people will work closely with the person you hire or have a stake in the person’s successful performance in the job. Some interview teams include patients or other people outside your organization who can help assess candidates’ suitability from other perspectives. Create interview time slots when all members of the interview team can be available so that you obtain complete sets of comparisons from all interview team members. Create or select questions to ask candidates to find out more about their approaches to work, how they treat patients and work with others in the organization, and the compatibility of their goals and values with the mission and vision of your organization and the goals of your



Hiring and Engaging People in a Culture of Well-Being

51

team. Rowley and Jackson (2011) and Sisson and Storey (2000) recommend that you structure your interviews to ask the same set of questions to each candidate to provide a basis for comparison. Include questions that ask about previous experience and others that are more situational or problem-solving to find out how candidates would handle real or hypothetical problems that are relevant to the job.39,40

Interviewing and Selecting: What Are You Looking for and What Should You Ask? Confirming Matches with Basic Requirements Different kinds of questions serve different purposes. Simple yes-no questions are closed-ended; they merely ask for confirmation or denial of specific information.41 These can be appropriate in brief screenings, with questions such as, • “Is your bachelor’s degree in nursing?” • “Do you have prescriptive authority?” • “Are there any limitations or exclusions on your license to bill your services to Medicare?” • “Have you worked in an outpatient setting before?” • “Are you licensed to practice physical therapy in Colorado?” • “Did you complete your residency at Mass General?” Of course, unexpected yes-or-no responses would prompt the screener to ask for more explanation that might result in a candidate being disqualified from further consideration. Behavioral Interview Questions Now let us consider how you can fill in more of the unknown picture of how the person will really perform when she comes to work on your team. Behavioral interview questions are designed to use information about people’s past experiences with real tasks and problems.42 The candidate’s responses can reveal what she is likely to do in future situations

52

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

she would encounter in the position. You can design them from realistic situations in your workplace. Often, they are worded as a request, such as “Tell us about a time when . . . And what did you do?” Here are some examples. • “Tell us about a team you worked on and what you did that helped it work well.” • “Now tell us about a conflict you experienced with someone you worked with. What was the situation, what did you say and do, and how did it work out?” • “Tell us about a patient you worked with who ignored your recommendations and their condition worsened. What did you say to them and how did they respond?” Notice how the behavioral questions ask about what the candidate actually said or did in the situation, not what they believe philosophically or theoretically should be said and done. This can reveal several things. Does the person really have experience in this area, or is he just describing what he thinks people should do if they found themselves in that situation? Listen for clues such as generalities and references to others rather than themselves, such as, “Teamwork is important. It helps when everyone pulls their weight and supports their teammates.” Contrast that vague response with this more specific one: On the team I work on now, people tell me they appreciate my pitching in when things get busy and tense. Yesterday when I was caught up on my rounds, I helped a new nurse who was struggling to give an injection to a frightened elderly patient. Another strength in the second response is the recency of the reference to things in the candidate’s current work and something she did just yesterday. The second behavioral question shown in the preceding text can help you learn more about the candidate’s style of communicating and working with others, along with her willingness to talk about difficult things. It is not unusual for candidates to respond to a question about conflict or things they perceive as negative by denying that they have ever



Hiring and Engaging People in a Culture of Well-Being

53

experienced them. Such a response might sound like this: “Oh, I don’t have conflicts, I get along with everyone!” This is where it is appropriate for you to probe further with follow-up responses. One could be, “What do you do to prevent conflicts? Can you talk about a time when you needed to do that?” Or another could be, “How about when you disagreed with someone else you worked with? What was the situation and how did you work it out?” Again, look for their specific references to themselves and their own behavior—are they able to take responsibility for their own actions or is there a tendency to blame problems on others? Perhaps you asked the third question, about the patient who ignored recommendations, because this happens a lot in your clinics and team members who are too forceful with their patients run into problems. The candidate’s response could tell you about her experience and likely approaches so you can determine how effective she would be. Oh, I remember that happened early on when I was just starting my practice. I had a stubborn patient who tuned out all my efforts to explain to him why he needed to take his medication. After he ended up in the hospital, he admitted he was tired of my nagging and wished he’d listened to me, but he had a hard time understanding my detailed explanations. I learned a lot from that, ended up apologizing, and asked him what kind of information would be more helpful to him. It turned out he preferred to read written instructions rather than listen to long oral explanations, so we agreed that I’d just tell him briefly what the medication was, print out the order with instructions, and he began to follow my recommendations. Now I ask my patients what would be helpful to them and since I started listening to them more, I get less resistance from them. Open-Ended Questions to Delve More Deeply Open-ended questions require more than a simple yes-or-no response and are designed to elicit more information and reveal details that you need to know. For example, asking, “I see you’ve been a licensed therapist for 15 years. In what state are you licensed now?” could reveal that the person has started the paperwork and is license-eligible but not yet licensed

54

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

in your state, so there could be delays in his eligibility to submit billable services in your organization. Open-ended questions also can delve deeper about people’s attitudes, preferences, and approaches. First, consider how a closed-ended question such as, “Do you enjoy working on teams?” makes it easy for a candidate to simply tell you what she thinks you want to hear by responding with, “Yes!” or an enthusiastic “Yes, of course, I’m a real team player!” Or, “Do you get frustrated with patients who ignore your recommendations?” might help you know how honest they are if he replies with, “No, I never get frustrated with any of my patients!” or “Sometimes, but I don’t let it bother me.” Now consider how much more you could find out by asking an open-ended question such as these. • “What did you enjoy about teams you’ve worked on, and what were some of the challenges?” • “What do you say to a patient with a serious health problem who has ignored your recommendations and his condition has worsened?” Exploring Styles and Approaches With open-ended and behavioral questions, there aren’t necessarily right or wrong answers; you are trying to get a sense of what it would be like to work with this person, how he would get along with others he will be working with, and how effective and successful he is likely to be in your particular organization. As Darcy Jaffe, explained, “I want people with a sense of joy in the world, who have hope and optimism and can transmit that.” In selecting and hiring new nurses, she looks for what people find fulfillment in, to determine whether they are a good match with values of the organization and its mission, which has been in place for over 50 years and “permeates everything we do.” It is about taking care of people from all walks of life.43 She looks at the attitudes people bring to work because of their impact on wellness on patients and the workplace, and finds out how candidates regard various populations of patients. So, it would make sense to ask questions that can reveal



Hiring and Engaging People in a Culture of Well-Being

55

people’s attitudes, beliefs, and preferences and the ways these affect their approaches to work. Consider candidates’ styles of communicating and working. If your organization is highly collaborative and a candidate reveals strong tendencies to issue commands to team members and compete with others in the organization, will that make it hard for the person to earn the cooperation of others to get things done? If the person is very laid-back and casual in a fast-paced environment that relies on formal hierarchies and established procedures, will that lead to problems? Or does the person offer special differences likely to bring benefits to the organization if she can effectively influence others to adopt new ways of doing things? Having a different style from others on your team might even be a good thing if it can help the team work through conflict constructively and arrive at better decisions. Do you see risks in hiring this person and do you see valuable enough benefits to justify the risks? How much are you, as the person’s supervisor, willing and able to support such contrasts in style and approach to ensure that your overall team operates effectively with productive relationships among all the members? Skills Demonstrations So, you have screened candidates to ensure they have the required credentials and qualifying skills and experience, and selected some for further interviews to explore how well they would work in your organization and team. How do you finalize your decision so you can proceed to offer the job to the most appropriate candidate(s)? For some positions, you may need to go beyond even behavioral interviewing questions so you can see exactly what the candidate can and would do if hired. You can narrow the group of finalists to a few and ask those two to three to prepare a presentation or demonstrate a key skill relevant to the actual things they would be doing on the job. For example, having the candidate show the interview team how she does treatment planning with a patient, or conduct a training session on a topic related to the position, allows members of the interview team to play the role of people who would be interacting with the person after he is hired, to ask questions and experience firsthand exactly how the candidate responds.

56

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

This will reveal important qualifications such as ability to convey caring and respect with patients, presentation and training skills, ability to explain things clearly, respectful interaction with class participants and ability to handle conflict or challenges in a training setting with employees in other roles in the organization. Role plays of other situations may be appropriate depending on the position. For example, for a patient advocate or position that conducts patient education group sessions, you might want to role play some typical scenarios the person would encounter in the position; you could include interview team members, or actual patients, to play the role of patients. Selecting the Right Candidate for Your Position All of these assessment activities, from screening to interviews to presentations and role plays, give you plenty of valid information to differentiate among candidates, fairly and legally, by applying the evidence you gather directly to the job requirements. If conducting training is an essential function of the job but some candidates lack effective training skills, you are justified in eliminating them. If your patients require a certain level of support and monitoring but some candidates are unwilling or not capable of providing that support, then you have reason to eliminate them. Often, it comes down to several candidates having the identified skills and abilities needed for the job, or there may even be one that stands out as most qualified, but you detect something concerning that could become problematic. What should you do? Getting More Information Several interview participants offered advice on this situation. Dixie ­Casford, VP of Acute Care at Mental Health Partners, described a time when an interview team had some concerns about the communication style of the candidate they found most qualified. They handled it honestly by sharing their concerns directly with the candidate and asking him to respond. The candidate admitted this was an area he had been working on and described the progress he was making. This opened the kind of honest dialogue we described in earlier chapters with the candidate offering



Hiring and Engaging People in a Culture of Well-Being

57

permission for others to offer feedback if they felt he was getting off track. The interview team appreciated the candidate’s self-insight and willingness to accept feedback, the candidate was hired, and was very successful in his role.44 Vicki Rodgers, Chief Operating Officer at Mental Health Partners, mentioned “red flags” she had seen through many years of interviewing and hiring. Sometimes, she explained, an interview team wants to hire someone, but as the hiring manager, you might have a feeling that there is something problematic about the candidate. She strongly recommends that you always check further. If you have concerns about their skills in some areas, ask for further evidence such as writing samples or showing you how they perform particular tasks. Delving into reference checks and talking to others who have worked with the person can help you find out what you need to know.45 New information might not necessarily eliminate the candidate from consideration. Rather, it might reveal things that can be discussed and worked out ahead of time with candidates so they do not become problems after they are hired. For example, maybe in the past a candidate was overly demanding with employees and this caused hard feelings and the exit of some key employees. Or, another candidate struggled to hold people accountable and this caused a past team to miss meeting some key deadlines. Asking about such issues can help identify patterns that signal future problems, or might reveal the candidate’s ability to learn from her mistakes and convince you of her self-insight and commitment to improve. Perhaps you would require the candidate, as a condition of employment, to complete some education or training or participate in developmental activities to address a weak area. Reference and Background Checks A formal reference check is normally part of confirming your final selection before you offer a candidate a job. It usually includes talking with at least three people who have worked with the candidate to confirm positions the candidate held, ensure performance was good, and she got along with others. Ideally, you would like to include some people who have directly supervised the employee, but often a candidate will not

58

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

allow you to talk to his current boss because he has not let that person know he is planning to leave his current job. Reference checking involves some time and expense, especially when it includes verification of licensing and other credentials. Some positions require criminal background checks and verification that the person has not been excluded from providing treatment or billing payers such as Medicare. Thus, it is normally done at the end of your interview and selection process for the final candidate, or when you have a few final serious contenders for the position. In most organizations, the HR department conducts the final reference and background check. Some organizations leave the reference check to the hiring manager, or you might conduct it earlier if you detect discrepancies or foresee potential problems, as described above, and want to probe for specific information. HR Adds Valuable Wisdom and Experience You should always pay attention to feedback from your human resources team. Jeff Tucker, VP of human resources at the Mental Health Center of Denver, reminds us that the HR team interacts with candidates throughout the process when you are not there. They know if candidates are courteous or dismissive to the receptionist when they arrive for their interviews, prompt or tardy in responding to communication, professional or overly casual in their interactions.46 If there are problems occurring with some candidates and their interactions with others in the organization before they are even hired, when they should be on their best behavior, what will they be like afterward? Our HR team helped us avoid a serious problem when a team I was managing had a difficult time finding the right candidate for an open position. After many unsuccessful interviews, my team finally settled on a finalist and presented him to me for a final interview. I shared the enthusiasm of the hiring manager and her team for this candidate, who was very likeable, interviewed well, and demonstrated strong knowledge of the function he would be working in. At the final steps of working with HR to prepare an offer, the hiring manager received a call from our HR manager, who started with, “Oh, my,” and we knew it was not good news. “I’ve never seen anything like this.” He shared with us the results of the



Hiring and Engaging People in a Culture of Well-Being

59

reference check and background check, with state arrest records, that corroborated the candidate’s experience in a similar earlier job . . . Where he had been accused of theft, had committed other unethical activity, and accumulated a history of criminal activities that were incompatible with the standards and requirements of our position. Our collaborative HR manager never told us we could not hire this candidate, but we could clearly decide based on the evidence that we certainly should not! It does take time and effort and it is better to wait to find the right candidate for the position you are filling rather than hire just to get a position filled. You should never settle for less than the best when hiring. Bringing in the wrong people can do much harm to your organization, and as the last example demonstrates, can put the organization at serious risk of harm. In that case, we waited and eventually found an excellent candidate, who happily accepted our offer and thrived in the position.

Compensation, Terms, and Job Offers As shown in our roadmap above, you will work closely with your human resources department to determine an appropriate salary, terms and conditions, and present the job offer to your selected final candidate. As much as you may want to advocate for maximum pay and the most favorable terms for a candidate you view as especially valuable, you cannot determine salaries and benefits without the involvement and support of your HR department, which holds the responsibility for ensuring fair and reasonable salaries among job categories across the organization, based on required credentials and experience and in consideration of market comparisons for equivalent jobs in other organizations in your hiring location. Positions are often organized into job groups or families that may contain entry-level and more senior levels of experience or credentials— for example, Imaging Technician I–III, or Case Manager I–II. Pay ranges, benefits, and other terms of employment usually follow standard guidelines for specified salary grades associated with increasing levels of responsibility and compensation in the organization. HR will work with you to determine the correct level that matches your selected candidate’s credentials and experience, and an appropriate point within the salary range. Often there is consideration for a candidate’s current salary, and it

60

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

is desirable to offer the person your position at a point that is somewhat higher than her current salary if that is possible without creating inequities compared with other team members with similar credentials who have been working in the organization awhile. This is where you really need the perspective of your HR team to compare salaries in positions of similar skill and responsibility across the organization to ensure fairness. Usually you will avoid offering a salary at the very top of the range for the position because it is desirable to leave some room for growth of skills and annual increases. HR will also ensure compliance with labor laws and any special labor contracts, such as an employee labor union contract, in effect in your organization. You will need to work within the hiring budget for your team or department. Going beyond the limits of your salary budget may require special approval from your accounting and finance department, and will likely require that you delay other hiring or reallocate expenses from somewhere else to offset the additional expense and ensure that the overall budget balances.

Welcome Aboard and Setting the Tone The important word here is “welcome!” You want your new employees to feel comfortable, wanted, and supported when they arrive and get started. The process is referred to as onboarding to help new employees assimilate into their new organization and roles. Most organizations offer some kind of formal orientation and introduction to company policies and procedures. Even better is for you to connect in person with everyone you hire who reports directly to you. Show them around when they arrive, introduce them to others. If you cannot be present and available when they arrive, make sure you have assigned someone to do this. Take your new employee to lunch on the first day or make sure the person is included in lunch plans with other team members or a group orientation activity for all new employees. Darcy Jaffe, who has high retention rates with very few employees leaving her teams, explains that in her organization, new hires get mentors and metrics. So, they know right away what they need to do and they have someone to help them learn how to do it. Departmental goals are



Hiring and Engaging People in a Culture of Well-Being

61

assigned to new people with follow-up on a monthly basis. They review these with their managers and set improvement goals.47

Chapter Summary and Key Points In this chapter, we looked at how an organization built a strengths-based culture of well-being for its employees. You can adjust and adopt these approaches to build a positive culture in your workplace. By focusing on employees’ strengths, you can attract and select people to join your team who will bring value to your team and complement the strengths of your other members. You saw a hiring roadmap that helps you navigate the steps of the hiring processing as you find and select the right candidates to fill open positions, and learned how your human resources team can help you as you build and develop a cohesive team of capable and engaged members! Key Points: 1. People are valuable! According to many reports, labor represents about 50 percent to 60 percent of hospital costs and is the greatest driver of operating expenses. 2. When people leave to work elsewhere, turnover costs are very high with searching, selecting, hiring, training, and supervising employees. Choose wisely and set a positive tone for the people you hire! 3. It is worth building a positive work culture; such workplaces enjoy much lower employee turnover. 4. You can contribute to high trust in your workplace by being a leader who is perceived as competent, communicative, honest, respectful, and fair. 5. Focus on what people do best to help them be most effective and engaged at work. Emphasize strengths and possibilities rather than weaknesses and limitations. 6. When hiring and developing your team, look for ways to fill in areas where your team does not have collective strengths. Consider how to round out your teams by adding people with valuable strengths to complement those already on the team.

62

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

7. Include other people in your interviewing and selection process, especially those who will work closely with the person you hire or have a stake in the person’s successful performance in the job. Some interview teams include patients or other people outside your organization who can help assess candidates’ suitability from other perspectives. 8. When positions open up on your team, be sure to communicate with your boss and your human resources team and make sure you cover all the necessary steps in hiring. 9. Utilize your human resources team. They have wisdom and experience to help you make good hiring decisions, set fair and appropriate salaries, and avoid legal problems. 10. Past behavior can help predict future performance. Ask open-ended questions to find out what candidates have actually done and how they are likely to respond in your workplace. 11. Seek additional information to resolve questions or concerns about job candidates. Pay attention to reference and background checks. 12. Make your new hire feel welcome and set the stage for her success. Arrange to meet and greet her on the first day and connect her with teammates who can help her get started.

Learning Activities for This Chapter 1. What practices of great places to work would you like to apply in your organization? a. Which of these could you begin to apply right now on your team? b. What resources or approval do you need for other efforts: for example, money for training and strengths assessments, support from upper management to implement new organizational practices, employee engagement surveys and analysis, and so on? 2. Refer to the Roadmap to Hiring shown in this chapter. Consult with others in your organization who are involved in hiring, especially your boss and human resources manager, to develop a checklist that covers the steps you need to follow for hiring. You may start with the form provided in Table 2.3 and add to or modify it for what is needed in your organization. Then, refer to it when you need to fill positions.



Hiring and Engaging People in a Culture of Well-Being

63

Table 2.3  Form for roadmap to hiring

Hiring Activity

Consult with (name, Date Completed? position) scheduled Date

1. Identify position to fill: New or Replacement? 2. Evaluate needs for position and qualifications 3. Review job description, adjust as needed 4. Contact HR to post position 5. Post and disseminate job announcement 6. Review applications 7. Assemble interview team 8. Develop interview questions 9. Schedule interviews: Round 1 10. Schedule interviews: Round 2 11. Select final candidate(s) 12. Conduct reference and background checks 13. Assemble job offer 14. Present job offer a. If accepted, set start date b. If declined, return to #10 or #11 to select next candidate, or to #9 if no other candidates are appropriate. 15. Notify other departments when candidate accepts, enroll new hire in startup activities 16. Welcome new employee on first day and assign a teammate to help her get settled

3. What qualities do you need in all the people you hire, regardless of the position or credentials? Consider communication styles, attitudes, preferences, and other important things that impact their success in working with others in the organization, the patients your organization serves, their ability to get work done effectively, and so forth.

64

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

4. After candidates are screened for meeting the credentials and experience required in the position, what behavioral interview questions will you ask? Check that each question is important and relevant for the job at hand and does not discriminate unfairly against any protected groups or individuals. 5. For specific jobs on your team, what other specific behavioral interview questions would you ask or demonstration activities would you conduct for your selection? 6. What onboarding and orientation activities are offered by your ­organization? What else do you need to do to welcome your new employees and get each of them off to a successful start? 7. Draft a “word picture” with clear and specific descriptions of the performance expectations and behaviors for someone working in a job on your team. Think of specific things you have seen people do that would make it clear what behaviors you would like a new employee to eliminate or emulate. For more on “word pictures,” see Volume I, Chapter 2. 8. How could you assess and leverage your strengths and those of your team members to boost your team’s effectiveness? a. Does your organization already use any formal assessment tools of strengths or preferences in communications or work styles? b. Are there other tools or approaches you would like to try? Consider those mentioned in this chapter or conduct your own online searches of what is available, including some free online tools. c. What have you observed about your employees and the different things they each seem to gravitate toward using naturally and doing well? d. What projects or activities can you identify that would benefit from combining the complementary strengths of some of your team members to cover a comprehensive set of skills needed for overall success?

CHAPTER 3

Business Basics: Finance and Budgeting Are Not Just for Accountants! Chapter Overview Why do you need to know budgeting and finance? This chapter will answer this question by explaining some basic financial and budgeting concepts, why they are important for every manager to know, and how an effective manager uses these ideas. We will look at financial aspects of your organization which you need to know about to manage effectively. We start by reviewing why money is important to keep your organization and team running. We will explain budgeting and examine an example of a team budget to help you see what you need to track and manage. We will look at some financial measures for your organization and help you interpret them to understand the financial health of your organization. Topics in this chapter: • Why money matters • Profit: What it means and why it is important, even in nonprofit organizations • Budgeting for what you are managing • Your budget: What does it look like and what does it tell you? • Big picture financial health of your organization • Recommendations for successful financial management • Applying financial principles in clinical practices • Chapter summary and key points • Learning activities for this chapter

66

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Why Money Matters Jim Collins (2001), in his popular book, Good to Great, urges leaders to understand, “What drives your economic engine.”1 Think of money as the fuel that keeps your organization running. As we will see in the classifications below, the majority of hospitals in the United States operate as notfor-profit organizations. This is also the case for many community-based health clinics. This means they exist to serve community needs rather than to generate profit for investors. However, all organizations, even those that are driven by their mission to serve rather than to help investors make money, must generate or receive enough money to cover the costs of their facilities, employees, equipment, supplies, direct care activities, and all of the other expenses necessary to keep the organization running. This includes the costs of indirect administrative processes that handle information, billing, and reimbursement for patient treatment and overhead costs such as maintaining the facilities. The reminder, “No money, no mission,”2 is often heard particularly in not-for-profit organizations.

Classifications Consider the percentage of health care organizations that are not-for-profit—existing to fulfill the needs of society and the people served rather than to generate financial returns for any private interests or investors—versus for-profit. Based on the latest survey of U.S. Hospitals in 2016 as reported by the American Hospital Association,3 of the 4,840 U.S. Community Hospitals4 included: • 59 percent = 2,849 are Nongovernment Not-for-Profit Community Hospitals • 21 percent = 1,035 are Investor-Owned (For-Profit) Community Hospitals • 20 percent = 956 are State and Local Government Community Hospitals There are more than twice as many nongovernmental not-for-profit hospitals as either investor-owned for-profit or state and local government



BUSINESS BASICS

67

community hospitals. Regardless of an organization’s mission and classification with regard to for-profit or not-for-profit status, money is necessary to cover all the activities and resources a health care organization relies on to deliver care to its patients. Minding Your Business: Why Worry about the Money? What are your beliefs and attitudes about managing money? You probably do this already in other areas of your life, particularly with a budget for home and family. The basic principles are straightforward as you ensure that you have enough money coming in or saved to cover your expenses. This is usually manageable when you understand where your money is coming from—your income—in the form of paychecks and perhaps other sources such as dividends or interest from investments and savings, rental income, and so forth. And you incur costs for purchases plus recurring expenses such as rent or mortgage, car payments, other loans, and expenses for food, clothing, utilities, entertainment, and things like that. Maybe it is someone else in your family or household who manages the money, makes sure bills get paid each month, and that you are setting something aside for emergencies, later expenses, and the future (for example, college for kids, retirement for you). Still, you usually know how much money you need to cover your more immediate expenses, and it is a good idea to know what is in your bank account before you write a check, withdraw funds from an ATM, or charge a large purchase to your credit card. Matching Clinical Practice to the Economics Now, let us step back and see how these basic principles of budgeting and money management apply in running a health care practice. As Fred Michel, MD, observed, “We need to match our clinical practice to the economics.”5 This means operating efficiently and within our budgets, keeping an eye on our expenses (money being spent to operate the health care organization) relative to revenues (or income, the money coming in). There are many requirements and nuances of health care that can make it particularly challenging to manage and administer these economic issues,

68

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

especially money matters that are largely driven by regulated funding sources such as public funds and private insurance companies. A number of the people interviewed for this book noticed that many health care practitioners may prefer to avoid the business aspects of running their practices, or just may not feel they have the skills to do this effectively. This is not surprising, as many of us chose to enter clinical or medical professions because we wanted to help our patients or clients lead better, healthier, or happier lives, not because our primary motivation was to understand billing rules and accounting practices. Many of us enter our fields of wellness with limited business knowledge. Let us look at some key concepts that can help you understand important financial principles and apply them confidently for effective business-oriented management.

Profit: What It Means and Why It Is Important, Even in Nonprofit Organizations From the report of the American Hospital Association at the start of this chapter, we have seen that the majority of hospitals in the United States are classified as not-for-profit (also referred to as nonprofit), and this is true of many other health care organizations that are not hospitals, especially outpatient community health centers providing safety-net services ensuring that people who need health care treatment and services receive them regardless of their ability to pay for them. Internal Revenue Code 501c(3) “provides exemptions for organizations organized and operated exclusively for charitable purposes, where no part of the net earnings inures to the benefit of any private shareholder or individual. An organization cannot be organized or operated exclusively for charitable purposes unless it serves a public rather than a private interest.”6 You may also hear such mission-based health care organizations referred to as nonprofit, not-for-profit, 501c(3), or tax-exempt organizations. Such organizations exist not to generate profits for shareholders or private individuals, but to provide benefits to the communities and patients they serve. And remember that nonprofit status does not mean the organization cannot or should not make a profit to cover its costs. In fact, it should generate enough revenue through billable services to patients, or receive enough funding through other sources (grants, private



BUSINESS BASICS

69

donations, or government funding) to cover its costs of operating! Generating a profit is important for the organization to sustain its important and beneficial work; qualifying for nonprofit status and tax exemption merely acknowledges that the organization serves the public good rather than the financial interests of any shareholders or individuals. Consider net profit (earnings before taxes), which is defined simply as: Net Profit = Total Income - Expenses When an organization’s net profit is positive, that means the organization produced enough revenue, or received other support, to cover its costs of operating.

Budgeting for What You Are Managing Budgeting Begins at the Top Budgets for the overall organization are developed at the executive level of the organization with guidance from the accounting and finance department, which provides the structure on revenue and expense categories along with data on actual revenue and expenses for past and current periods and forecasts of year-end results. They also develop the statements of the organization’s overall financial position—the balance sheet, income statement (profit and loss), and cash flow reports, along with other key ratios and metrics that describe the organization’s financial health and status. You can find out where the overall financial statements for your organization are disseminated and distributed, and it could be worthwhile to schedule time with your accounting department to review them, discuss their meaning and implications, and discover levers for you to focus your team’s efforts on. Later in this chapter, we will look at these broader organizational financial statements, in which the summary-level budget for the overall organization may provide the capability to expand the details for specific items, departments, clinics, or teams. More immediately, however, the key tool you need to work with directly as a manager is your budget for the specific teams or functions

70

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

you are responsible for. This is where you allocate and track the money allocated to cover the costs of your team’s operations, and the revenues expected to be produced from the services (and possibly goods) provided to patients. Let us focus now on what you need to manage for your area of responsibility at the level of the team or clinic you manage. Know What You Are Responsible for Usually, if you have the responsibility and authority to hire and manage other staff members, you have a budget, but this is not always the case. Sometimes several teams or departments share a budget that is rolled up and managed by managerial leaders above you. As emphasized throughout this book, it is important for you to find out the extent of your responsibilities in your management role, especially for managing revenue and expenses. If you have responsibility for managing any budgets, you should obtain, review, and verify your initial budget and ongoing periodic reports that show changes over time and current status. If you have not seen these, you need to request them from your accounting department. It is important that you check the contents and the formulas that go into your budget so you know or can ask for clarity about what is included and how things are calculated. You cannot manage what you cannot see! I have known managers who were not aware they were expected to manage several particular staff members or clinical service components until they discovered them listed on their budgets—sometimes in error, left over from prior budget years, and other times accurately, but unbeknownst to the new manager. How to Spend and Track It is important to know how to spend company money for nonroutine needs that arise at work, outside of regular purchasing and ordering activities. It will empower you to make the spending decisions that are within the authority of your position without having to ask your manager about inconsequential purchases and expenses that you can handle yourself. Understand the difference between small, inconsequential purchases like



BUSINESS BASICS

71

a coffee maker or specialized office supplies, which you probably can initiate yourself, versus major investments for equipment costing hundreds of thousands of dollars, or multimillion dollar buildings, which require much more financial analysis and approvals at executive levels! You probably will be able to order inexpensive items yourself such as a small replacement coffee maker for the staff break room or specialized office supplies that are needed to support a special project. Work with your purchasing department, especially for routine supplies for which they typically negotiate bulk pricing with their vendors and find out their procedures for handling nonroutine purchases and replacements. Find out what channels and processes you should use to buy and spend for the relatively inexpensive things your team needs, along with the cycles and deadlines for ordering routine supplies and nonroutine special items. Before you make any nonroutine purchases or expenditures, you should know, or find out: 1. Regular ordering and purchasing cycles 2. Your spending limits 3. Who else needs to approve and sign requisitions for special purchases 4. What categories (accounts) in your budgets or other organizational budgets the expenses will get charged to 5. How much is available (budgeted and not yet used) for you to use in the appropriate categories. The more you understand about the budgets and financial resources you may access, the more effective you will be in managing your team’s work and handling the organization’s resources efficiently. Next, we will look at budget cycles to help you plan effectively to allocate financial resources. Budget Cycles and Fiscal Year Periods Budgets are usually developed for each fiscal year. They are prepared to begin at the start of the fiscal year, which might be something different from a traditional calendar year that begins on January 1. For instance, in Colorado, the state fiscal year runs from July 1 to June 30,

72

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

so community health organizations that receive major funding from the Colorado Department of Healthcare Policy and Financing also follow this fiscal year. Some of the health care organizations refer to their fiscal years by the year at the end of the period; for these organizations the budget year for July 1, 2019 to June 30, 2020, would be referred to as Fiscal Year 2020 (typically referred to as “FY 2020.”) Others might include both the starting and ending year for clarity, so they would refer to it as FY 2019–2020. For clear communications, find out the dates of the fiscal year in your organization and the correct way to refer to it. You also should ask about the timing and cycle for preparing and finalizing budgets so you can make appropriate and timely recommendations and input into it. This is crucial if you need to request more resources, especially staffing. It becomes very difficult to obtain such resources later if they were not budgeted anywhere (unless your organization follows a practice of rolling budgeting that makes adjustments as needed throughout the fiscal year based on changes in financial position.) If your position, team, or department was created recently, your finance and accounting team might not have split it yet into a separate budget entity for reporting and accounting, especially if this change occurred after the start of a fiscal year budgeting cycle. Other exceptions could occur if new programs or services start up within a fiscal year (perhaps as the result of funding that becomes available through grants, major donations, or other sources such as unexpectedly high revenues and profit, or in response to crucial community or patient needs), or as the result of reorganizations that change structures and reporting relationships among teams or departments.

Your Budget: What Does It Look Like and What Does It Tell You? The following budget example (Table 3.1) is based on a format used by one nonprofit community health care organization, with representative items in an annual budget for a hypothetical clinical team that delivers



BUSINESS BASICS

73

Table 3.1  Budget example: children’s health clinic team A

Account # Description

FY18 Budget

Projected End of YTD 3rd Fiscal Quarter Year

Variance

Budget FY19

4320

Insurance

$423,200

$121,500

$162,000

($261,200)

$162,000

4540

Medicaid

$544,300

$539,877

$719,836

$175,536

$791,820

4774

New Children’s Wellness

$12,000

$10,899

$14,532

$2,532

$14,532

4779

New Children’s Prevention

$8,450

$7,000

$9,333

$883

$9,333

 

  Federal Grants

$20,450

$17,899

$23,865

$3,415

$23,865

 

  Total Revenue

$987,950

$679,276

$905,701

($82,249)

$977,685

6010

Gross Wages Paid

$608,500

$507,155

$676,207

$67,707

$696,493

 

 Wages

$608,500

$507,155

$676,207

$67,707

$696,493

6210

FICA

$46,550

$38,797

$51,730

$5,180

$53,282

 

  Payroll Taxes

$46,550

$38,797

$51,730

$5,180

$53,282

6310

Company Claims

$71,850

$67,049

$89,399

$17,549

$89,399

6320

Other Insurance

$27,823

$21,760

$29,014

$1,191

$29,014

 

 Insurance

$99,673

$88,809

$118,412

$18,739

$118,412

 

 Total Personnel Costs

$754,723

$634,762

$846,349

$91,626

$868,187

8010

Computer Services

$13,769

$17,401

$23,201

$9,432

$23,201

8015

Computer Software

$10,383

$55,885

$74,514

$64,131

$74,514

8020

Computer Supply

8025

Computers

8125

$187

$584

$779

$591

$779

$0

$5,789

$7,719

$7,719

$7,719

Property Expensed

$853

$761

$1,014

$161

$1,014

8165

Conference Travel

$12,006

$12,384

$16,512

$4,506

$16,512

 

 Operating Expenses

$37,199

$92,804

$123,739

$86,540

$123,739

8210

Equipment Lease

$532

$454

$606

$74

$606

8215

Occupancy Insurance

$322

$229

$305

($16)

$305

8230

Rent

$1,434

$1,232

$1,643

$209

$1,643

(Continued )

74

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Table 3.1  (Continued)

Account # Description 8270

Repair/ Maint-equipment

8280

Repair/ Maint-facility

8285

Security-facilities

8322  

Projected End of YTD 3rd Fiscal Quarter Year

FY18 Budget

Variance

Budget FY19

$84

$37

$49

($35)

$49

$3,237

$3,227

$4,303

$1,066

$4,303

$58

$43

$57

($1)

$57

Electricity

$2,713

$1,729

$2,305

($408)

$2,305

 Occupancy Expenses

$8,379

$6,951

$9,268

$889

$9,268

8630

Insurance

$3,702

$3,156

$4,208

$507

$4,208

 

 General & Administrative

$3,702

$3,156

$4,208

$507

$4,208

9210

Depreciation & Amort

$21,505

$12,476

$16,635

($4,870)

$16,635

9820

Loss Disp of Asset

 

 Depreciation/ Amortization

9996

Admin Allocation

 

 

   

 

$0

$0

 

$0

$21,505

$12,476

$16,635

($4,870)

$16,635

($161,617)

($152,606)

($203,474)

($41,857)

($203,474)

 

 

 

 

$0

  Total Expenses

$663,891

$597,543

$796,724

$132,834

$818,562

 Net Income (Loss)

$324,059

$81,733

$108,977

($215,082)

$159,122

health care services for children and belongs to a larger nonprofit community health care organization containing several similar teams in different locations. Budget Example Let us suppose the budget was created in the fourth quarter of Fiscal Year 2018, after the end of the third quarter when data for the first three quarters of the year were reported and totaled, to prepare for budgeting for the next fiscal year, 2019. Financial values and other details were developed in this example to illustrate general budget concepts and explain



BUSINESS BASICS

75

some particular situations, and are not taken from an actual clinic. Before we look at the budget items in the rows, let us look first at the columns, which represent time periods.

Time Periods and Comparisons of Numbers: Column Headings and Their Meanings The five columns with financial numbers in them represent what was budgeted (what was expected), what actually happened during the fiscal year, projections based on current status, differences between projected year-end budget performance and what was budgeted for the year (variance), and budget for the next fiscal year (shown in this example, but usually not shown in early periods of a current fiscal year.)

Budget for Current Year The first, FY18 Budget, is shorthand for the current year budget (at the time represented in the example) for “Fiscal Year 2018,” the fiscal year that ends on June 30, 2018 for this particular organization that starts its fiscal years in July. Assume this is the current fiscal year of operation and the numbers represent the revenue and expenses that were allocated in the prior fiscal year when the budget was developed for this fiscal year’s operations. These are the revenues (or income) and expenses that were expected to occur in the current fiscal year. Year-to-Date Progress The next column header, YTD for Quarter 3, represents the numbers that have been reported, accumulated, and totaled for this budget year to date. In this example, the numbers are generated after the close of the third quarter, so the numbers represent three quarters of a full year of actual (not expected) operation.

76

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Projected Results for the End of the Fiscal Year The next column, Projected, represents the projection of year-end results for each revenue or expense item in this budget. This is simply an extension of three quarters of the year into a full year, dividing each number shown in the YTD column by 3/4. For example, if after three quarters of the year, the clinic had received revenue of $539,877 from Medicaid (Account Number 4540), then by the end of the fiscal year the expected amount of revenue received for the full four quarters would be $539,877/ (3/4) = $539,877 × 4/3 = $719,836, which is shown in the column for Projected End of Fiscal Year. However, you need to consider the things that typically occur in different quarters or seasons and will cause your actual year-end results to be different from this direct arithmetic calculation based on part of the fiscal year. Keep this in mind when planning so you realistically balance your income and expenses as they occur. Variance Variance represents the difference between the projected year-end numbers and what was budgeted for the fiscal year. Variance is favorable if you are bringing in more revenue or spending less than expected. It is unfavorable if revenue is lower or expenses are higher than expected. This is an important indicator for you to use to gauge whether your budgetary management is meeting, exceeding, or falling short of expectations. In the later subsection on observations about this budget, we will consider more closely what the variance in this particular budget reveals. Budget for the Next Fiscal Year This column, which is labeled ‘Budget FY19’, usually will not show up until late in the current fiscal year when it is time to budget for the next fiscal year. Let us assume for this example that we have completed the third of the four quarters in the current fiscal year and we are planning now for the next fiscal year. In this example, the organization bases its next year’s budget heavily on the projected year-end results obtained



BUSINESS BASICS

77

from the current year’s actual income and spending so far. Be aware that there are other methods of building budgets, but for simplicity, we start with this method for illustration and make adjustments as described below. For many of the revenues and expenses in this example, the projected number for the end of the current fiscal year is simply moved to the budget for the next fiscal year. But in this case, let us suppose the organization has negotiated a 10 percent increase in the value of its Medicaid payment contract, so the number in the next column, $791,820, is calculated from $719,836 × 1.10 = $791,820. Likewise, for salary expenses, suppose the organization plans to apply a 3 percent Cost of Living Adjustment (COLA) to increase every employee’s salary by 3 percent. This is reflected in the higher amounts for salaries and expenses for FICA (which stands for “Federal Insurance Contributions Act”) in the next fiscal year 2019. Chart of Accounts: Rows for Income and Expenses The rows in this example show account numbers and descriptions that come from the organization’s chart of accounts (COA). The COA lists all the accounts available to record financial activities in the organization’s general ledger, which provides a complete record of all the organization’s financial transactions as money is received and spent to create financial statements such as balance sheets of company assets and liabilities, income statements (also referred to as profit-and-loss statements), cash flow reports, and other analysis. We will see examples of these organizational financial statements in a later section. Your budgets might not show all the details from your organization’s chart of accounts, but be assured that there is a general ledger being used to record the organization’s incoming income (revenue) and expenses (costs), and track the organizational group (team, department, or cost center) associated with each item so the accumulated totals for each account show up in the correct budgets and reports. For conciseness of this example, many typical details of accountlevel items were eliminated. Some organizations consolidate many of the

78

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

categories—for example, rather than break out expenses related to payroll and benefits, your organization’s budgets might show just a percentage for “Employee benefits,” “Fringe benefits,” or something similar. Your budget format will differ according to your organization’s standards and budget process, but the general principles will be similar. For instance, the Account Number column you see in this example represents this organization’s chart of accounts from its general ledger that is managed by the accounting department. Most organizations have their own systems or software packages that generate chart of account numbers and track the income and expenses that accrue to the accounts. These account numbers are organized by categories—in this example, the items in the 4000 series refer to revenues produced by your team. The 6000 series refers to your team’s salaries and benefits. This budget example shows details of employee benefits such as payroll taxes, health insurance premiums, and insurance claims incurred by members of this team. Income Sources Health care organizations generate revenue from several kinds of income sources. We see in this budget example that this Children’s Health Care Clinic run by Team A has four sources of Revenue from Account 4320 for private insurance (nongovernmental), Account 4540 for Medicaid, and two federal grants shown in Accounts 4774 and 4779. Insurance and Billing Typically, a large portion of the revenue comes from public and private insurance, administered through contracts with payor organizations and fee-for-service billing based on treatments and procedures performed. Depending on the type of services provided and the patients receiving them, some services are paid for directly by the patients themselves. (There are no self-pay sources shown in this example.) Grant Funding The example shows the team is receiving some new federal grants for children’s wellness and prevention services. We see that the revenue for



BUSINESS BASICS

79

these grants is quite small compared to the other revenue sources from Medicaid and other insurance. Grants can be useful for helping providers start up new clinics and learn to operate new kinds of services, but very often the funding received does not cover the true costs of operating the program. Often there is an expectation from organizations that provide funding through grants that the funds will not fully sustain the ongoing operations, and the organization will learn to operate the programs profitably so they can become self-sustaining. If you are involved in applying for grants or managing clinical programs that receive grant funding, there are typically many requirements for tracking and reporting on your use of funding that are likely to involve additional administrative overhead expenses that give you a good reason to sharpen your budgeting skills! For more on grants, see Appendix A.

Expenses Personnel Costs From the figures in Total Personnel Costs and Wages we see that on top of direct salary to employees there is approximately 24 percent additional expense for employee benefits. This varies by organization, so if you want to plan your full staffing expense of the employees on your team, you need to find out from your human resources, payroll, or accounting departments what the average percentage is for fringe benefits and overhead expenses to be added to the salaries in your organization. Example of a Mandatory Expense in Your Budget Be aware that you will see in your budget some expenses that you cannot eliminate or control directly. For example, FICA (an acronym for the Federal Insurance Contributions Act) shows up as Account Number 6210, as part of the team’s personnel costs. It is a mandatory payroll tax that funds the federal Social Security and Medicare system that pays for retirement benefits, some disability payments, and Medicare health insurance.7 The calculation of FICA is simplified in this example as 7.65 percent of total employee wages. The actual calculation is more complicated with tiers of percentages applied at different ranges of salary; your

80

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

payroll or accounting department applies the federal formula to provide the actual numbers for your employees. Be aware that FICA is not optional or discretionary; the only way you can reduce its impact in your budget is to reduce the total amount of wages you pay your employees, or you might reduce the number of people who are actual employees on your payroll—for instance, outsource some work to other organizations or utilize self-employed consultants, but that will increase your expenses in other categories. FICA is just one example of several items that are assigned in your budget because of requirements outside your immediate control. Others include administrative and overhead allocations determined through higher-level financial analysis in your organization. Other Operating Expenses The 8000 series in this example contains other operating expenses incurred by or allocated to your team that are separate from employee salaries and benefits. The items in the 8000 and 8100 series are mostly things that are used by your team that you, as the manager are likely to have some ability to control or influence, although there will be exceptions. Other items in the 8000 and 9000 series are things that you do not control but still share in the overall expense to the organization, depending on how your accounting team allocates these expenses back to individual teams or departments. These are the expense categories in this example that total into the categories Occupancy Expenses (series 8200 and 8300), General and Administrative (8600 series), Depreciation and Amortization of major organizational assets (that could include buildings, furnishings, major equipment, and vehicles) in series 9200 and 9800. Administrative Allocation Then there is an Administrative Allocation, Account Number 9996 in this example, calculated by your accounting department. This operates like a credit to your budgeted expenses to acknowledge the organization’s need or commitment to support teams and departments that might be required to handle activities that cost more to operate than any revenue that comes in. This typically occurs in nonprofit organizations that provide



BUSINESS BASICS

81

treatment and services to underserved populations or to patients who are underinsured and unable to pay the full costs of their services and need the organization to extend charity care. Or it may be required to support needed and valued administrative departments and teams such as fundraising and public relations, billing and compliance, patient safety, quality management, information technology, and so forth. Health care organizations need to invest in infrastructure and staffing with employees and technologies that do not provide revenue-generating health care services themselves to the organization’s patients but they build the processes and provide the labor to ensure that services are correctly delivered, recorded, documented, submitted, analyzed, and monitored internally so all the revenue is captured and flows smoothly into the organization. Often it is wise and necessary for the organization to increase its spending and investment in these supporting administrative functions. For example, several years ago, community mental health care organizations in several states were feeling vulnerable to imminent intense federal scrutiny of their programs that increased the risk of high-impact audits that could require these organizations to return money that had already been collected for services delivered. Many of these organizations began to invest in increased internal audit programs and staff to interpret and ensure compliance with increasingly complex billing requirements. Thus, for the nonclinical departments responsible for these activities, the increased staffing increased the costs of their total wages and benefits, but the work they did protected the organization from serious fines and penalties that were likely to occur without the extra internal efforts and could seriously impact the organizations’ revenue and bottom-line profit. The cost of the extra staffing was less than the expected financial penalties that could lead to reduction in needed services to patients or prevent the even more disastrous risk of having to shut down altogether. Observations about This Budget Decisions and Impact Regarding Administrative Allocation In the example of this clinical team, the Administrative Allocation credits some expenses and results in a profitable bottom line, which we see in the positive net income numbers: for Fiscal Year 2018 budget, the net income

82

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

expected from budgeted revenues greater than budgeted expenses was $324,059. We know this was profit because the number is positive; if it had resulted in a loss, the number would be negative and expressed within parentheses as we see for the Administrative Allocation of ($161,617), which is, in effect, a negative (reversal of ) expense equivalent to a positive credit to the budget. Notice that at the Year-to-Date (column header “Quarter 3 YTD”) point, actual revenues are $679,276 and expenses are $597,543 after the Administrative Allocation reduced the total expenses by $152,606, resulting in a positive net income of $81,733. Without the Administrative Allocation, total expenses would be counted as $750,289 and subtracted from YTD revenue to result in negative net income of −$71,013, which would be expressed as ($71,013), with the parentheses indicating a negative value. This illustrates that finances are managed at higher levels of the organization to allocate excess funds from profitable areas where revenues exceed their expenses, to cover others that do not generate revenue or do not fully cover their expenses. These are deliberate business decisions that organizations may make to balance the organization’s values and requirements to serve its patients and community when there are known factors that impact the capabilities of some clinics or programs to run profitably. However, be aware of expectations for your performance in managing expenses for the area you are responsible for. Expect that there will be rigorous financial analysis to compare the operations and performance of different clinical teams and programs that can result in consolidation, reorganization, or elimination of less profitable ones. Expenses Exceeding Amount Budgeted Another notable issue is the large expense for computer software that exceeded the budgeted amount. This could represent some new required capability for reporting associated with the grants or other activities. It would be desirable that the additional costs of the software could result in enhancements to staff productivity that could boost efficiency to increase services to patients. Note that very expensive items that are invested in and implemented over time, such as a full electronic medical record



BUSINESS BASICS

83

system, appear in a separate organizational capital budget where they are handled with different accounting rules. A Closer Look at Variance and What It Signals It is useful to consider variances, or differences, between what was expected and what is actually happening. Based on what has happened so far in the three quarters completed of the fiscal year, it is apparent that some budgeted sources of revenue—for Medicaid and the two federal grants—are projected to be higher than expected at the end of the fiscal year. The other one, for private insurance payments, is projected to be much lower. A quick analysis of the revenue numbers in the budget confirms this. The projected negative variance, shown as $(82,249) for total revenue is unfavorable and signals that the favorable variance for Medicaid and the two grants does not cover the projected shortfall in insurance revenue. Furthermore, when we look at the total expenses at the bottom of the budget, we see unfavorable variance in expenses that are projected to be higher than budgeted. This resulting unfavorable variance in net income, shown as $(215,082) might signal a concerning trend that the team’s operations are becoming less profitable. Or this might be a case where this team’s work is supporting larger overall organizational goals, and the team is not expected to run as profitably while new foundations in practice and funding are being built to meet longer-term goals for community access and enhanced population health. As we have discussed throughout earlier chapters, especially in ­Volume I, Chapters 2 and 3, it is important for you to understand and manage such expectations. It could be helpful for you to track the work your team is doing, in terms that align with expectations such as increasing numbers of patients served, to provide visibility and recognition for the valuable contributions your team is making. Budgets and Formats in Your Organization Budgets for teams, departments, or clinics in most organizations are ­ typically organized as a profit-and-loss (or income-and-expense)

84

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

statement showing sources of revenue (income) and expenses (costs), as we have seen in our budget example. Your periodic statements of operations that you review regularly to track your ongoing financial performance may look similar in format. In this example and in many organizations, past performance is used as the starting point for building the next year’s budget. Other alternatives include zero-based budgeting in which assumptions and organizational needs are examined each year to determine what is actually needed at that point in time and the best way to allocate resources. Generalizing Budget Concepts The budgets you receive in your organization will look different in their details of some categories and descriptions, but many key concepts are the same. • Revenue and expenses apply in the same way as you manage these items and make sure you are on track for your team’s operations within your organization. • You might not see account numbers or columns like those in this example, as the structure of the budgets you work with in your organization are determined by accounting staff and the software programs they use to track financial information and develop budgets. • In any case, you will see descriptions that tell you what each item represents. • Many of the expenses relate directly to your team or area of responsibility. • You are likely to see expense items listed in your budget that you have no direct control over. Now that you understand the value of your local budget and how to manage it effectively, let us take a step back and look at finances for the larger organization so you see how your team’s work aligns with overall financial health.



BUSINESS BASICS

85

Big Picture Financial Health of Your Organization There are overall financial statements for your organization that help your senior managers, executive leaders, board members, and the community understand the big picture of how your organization is doing financially. Overall, is it healthy or in trouble? Are there important changes or trends to be aware of? Key changes to focus on include: • • • •

Revenues that are going down from earlier periods to now Expenses that are going up Insufficient assets to cover what the organization owes Long delays in receiving payment for services that have been delivered

What is happening that contributes to these problems? We describe here the three key financial statements to review that help you understand the finances of the overall health care organization you work in and we show a representative illustration of each.

Cash Flow Statement The cash flow statement answers the important question of where the organization’s cash went during a specified period of time. Cash flow is a particularly important issue in health care because of the high utilization of insurance payors along with governmental funds and other grants. Very often the ultimate consumer of services (the patient) is not the one paying for the services. With payment controlled by others and subject to administrative rules and often complicated processes, payments can be delayed and even withheld, which can limit our access to the resources we need to continue to run our clinics and facilities, pay our staff, and provide the care and treatment our patients need. Mohr (2003) explains, “The cash flow statement can take many formats but the most common one breaks down the statement into three sections: • Cash from operating activities. This could include the collection of receivables, payment of payables, and purchase of inventory.

86

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

• Cash from investing activities. This could include the purchase or disposal of equipment. • Cash from financing activities. This could include borrowing new money from lenders, repaying debt to lenders, new capital investments from the owners, and cash distributions to owners. The sums of all three sections of the cash flow statement plus the net income minus noncash expenses are combined to show the net increase or decrease in cash for the period.”8 Next, we illustrate a cash flow statement (Table 3.2). Numbers represent $1,000. Round numbers are used to simplify the illustration and make it easy to follow the calculations. Numbers in parentheses indicate expenditures flowing out of the organization, which are calculated as negative contribution to cash flow. For example, (3,000) represents the $3,000,000 spent on inventory. This example shows that at the start of Fiscal Year 2017, the ­organization had $22,000,000 in cash. • Operations: In conducting its work of delivering health care services during the year, it received $34M and spent $23M in cash, for $11M net cash flow from operations. • Investments It conducted some investing activities by selling property and equipment that brought in $8M, and spending $20M on other property and equipment to result in net cash flow from investments of −$12M. • Financing There was some financing activity to repay a loan by spending $3M, which resulted in net cash flow from financing of −$3M. Totaling the results of these three types of cash flow activities shows that the organization had a −$4M net increase of cash. This means that in the Fiscal Year 2017 reporting period, the organization spent $4,000,000 more in cash than it received.



BUSINESS BASICS

87

Table 3.2  Cash flow example Cash Flow Statement For the Year Ending Cash at Beginning of Year

June 30, 2017 22,000

Amounts shown in $1,000 Operations

 

Cash receipts from  Insurance

16,000

  Government funding

7,000

  Other contracts

8,000

  Self-pay fees-for-service

3,000

Cash paid for   Inventory purchases

(3,000)

  General operating and administrative expenses

(6,000)

  Wage expenses  Interest   Income taxes Net cash flow from operations Investing Activities

(12,000) (2,000)   11,000  

Cash receipts from   Sale of property and equipment

8,000

Cash paid for   Purchase of property and equipment

(20,000)

Net cash flow from investing activities

(12,000)

Financing Activities

 

Cash receipts from   Issuance of stock

 

 Borrowing

 

Cash paid for   Repayment of loans  Dividends

(3,000)  

Net cash flow from financing activities

(3,000)

Net Increase in Cash

(4,000)

Cash at End of Year

18,000

88

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

We see that the organization could sustain its ordinary operations through its positive net cash flow from operations. However, the large investment of $20,000,000 in property and equipment plus the loan repayment of $3,000,000 consumed more than the organization received for its investment and financing activities, and required using some of its cash reserves. This example showed cash flow during a full fiscal year. Statements for shorter periods can show monthly accounts receivables (the money that is owed to the organization for services that have already been delivered) and accounts payable (the money the organization owes to its creditors for goods and services it has already purchased.) It shows the organization’s ability to pay current expenses, particularly as a function of the amount of money owed to an organization for services and goods that have already been provided and the length of time it takes to receive payment. Remember that cash flow considers cash coming in along with cash going out of the organization. This is why it is often necessary to wait to purchase expensive new things until the liquid resources (which means readily available cash) are available to pay for them. Decisions to make expenditures that result in negative net increase in cash, like what we saw in the example, are made at high levels of the organization and often require approval of the board of directors or board of trustees of the organization. Income Statement The income statement is also referred to as a profit-and-loss statement. Think of it as the overall budget for the organization. It shows the difference between revenue (income) and costs (expenses), to show profit over a given period of time from service delivery to payment. Jeremy Donai (2014) provides financial definitions from the perspective of an audiology clinic. In his explanation, the income statement lists income (also referred to as revenue), which comes from services to patients and sales of merchandise such as hearing aids in his example, costs (also referred to as expenses), and the difference between the two, which is net income (also referred to as profits, or losses) over a given period of time.9 The income statement is where you can find out your organization’s overall profitability, as bottom-line profit and profit margin.



BUSINESS BASICS

89

You will also see the organization’s revenues and expenses. Expenses are categorized as • Direct expenses of labor and supplies in delivering care and services • Overhead or Indirect expenses incurred to run the business, such as rent, utilities, and administrative costs Key results to focus on: • Revenue – Expenses = Profit before taxes. Profit before taxes –Taxes = Net Income (the “Bottom Line” profit). Note that nonprofit organizations, meeting the requirements of IRS code 501c(3), qualify for tax-exempt status; for such organizations, net income is simply the difference between revenue and expenses. Thus, • Net Income = Revenue − Expenses (for nonprofit organizations) • Net Income = Revenue − Expenses − Taxes (for for-profit organizations) • Net Profit Margin = Net Income/Total Revenue. (Multiply by 100 to express as a percentage.) Net Profit Margin is a ratio of the proportion of Revenue that is needed to pay the expenses for the health care organization to conduct its work. Net Profit Margin takes all business expenses into account. It indicates the percentage of income that remains after all expenses have been paid. Thus, higher margins indicate higher efficiencies. The organization must have enough revenue to cover its expenses. Too much expenditure on capital (for example, equipment and buildings) relative to income can put an organization at risk of financial failure; this would show up in lower net profit margin.10 Table 3.3 provides an illustration of an income statement.

90

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Table 3.3  Example of an income statement Illustration of an Income Statement For fiscal years ending June 30, 2016 and June 30, 2017 Amounts shown in $1,000 Revenue

2017

2016

  Billed services

30,000

20,000

  Grant funding

2,500

1,500

 Donations

7,000

6,200

 Consulting

1,000

800

  Other revenue Total Revenues

1,000

 

41,500

28,500

Expenses   Salaries and wages

6,000

5,500

 Rent

20,000

15,000

 Equipment

10,000

6,000

1,700

 

37,700

26,500

3,800

2,000

 Other Total Expenses Net Income  Taxes

1,000

900

  Net Profit

2,800

1,100

Net Profit Margin = Net Income/Total Revenue

9.16%

7.02%

Note that unlike in our cash flow statement, the income statement focuses on just the revenue and expenses from the organization’s operations, not including its separate activities for investing and financing. This explains why it is often necessary to wait until the organization’s financial position is in better balance before investing in major expenditures such as new buildings. Often the income statement will show only one period of time. This example includes two fiscal years so we can compare changes in financial performance from one fiscal year to another. In this example, revenue increased. If the organization was providing more services to patients, we would expect revenue to increase along with the expenses for staffing, space, and equipment to provide and support those services. The net profit margin shows that the organization generated more net income from its service operations, so it appears to be handling its increased service capacity efficiently.



BUSINESS BASICS

91

Balance Sheet The two previous types of financial statements we covered, the cash flow statement and the income statement, looked at the organization’s financial activities over specified periods of time. This included its generation and expenditure of revenues and its acquisition and disposition of capital and investment assets. The balance sheet, in contrast, focuses on the assets and liabilities (debts or money owed) that an organization has at a particular point in time. The balance sheet reveals the net worth (which may be referred to as shareholder equity in for-profit organizations) of the organization, as the difference between the organization’s assets that reflect financial value and liabilities that reflect what is owed, as a snapshot at a specific point in time. The key relationship is: Net Worth = Assets − Liabilities, at a particular point in time. Table 3.4 provides an illustration of an organization’s balance sheet. Remember, a balance sheet shows the organization’s assets and liabilities at one particular point in time. For this example, we display the numbers for the same point in time in two different fiscal years so we can see how an organization’s financial status has changed from one point in time to another (in this case, the halfway point of two fiscal years for an organization whose fiscal year runs July 1 to June 30.) Notice that the organization’s total assets are the same from one year to the next, but there has been some movement of its cash, assumption of long- and short-term debt, and apparent investment in property and equipment. These activities might have been needed at the time to cover necessary expansion to meet growing needs for services. However, we see in the Common Financial Ratios that these activities changed the organization’s financial position for what it can afford to do next. It has assumed more debt, decreased its ratio of current assets to current liabilities, and has negative working capital because current liabilities exceed current assets. Why are these ratios important? They signal the financial health of the organization. For those who might want to invest in the organization

92

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Table 3.4  Example of a balance sheet Illustration of a Balance Sheet

Date: December 31, 2017

Amounts shown in $1,000

 

Assets Current Assets

  2017

2016

 

 

20,000

50,000

  Accounts receivable

2,000

2,000

 Inventory

1,000

1,000

 Cash

 Supplies Total current assets Fixed (Long-Term) Assets

3,000

3,000

26,000

56,000

 

 

  Property, plant, and equipment

55,000

25,000

 Equipment

10,000

10,000

Total fixed assets

65,000

35,000

91,000

91,000

 

 

Total Assets Liabilities and Net Worth Current Liabilities

 

 

  Accounts payable

10,000

10,000

  Short-term loans

25,000

5,000

6,000

6,000

41,000

21,000

 

 

Long-term debt

10,000

2,000

Total long-term liabilities

10,000

2,000

  Accrued salaries and wages Total current liabilities Long-Term Liabilities

Equity Other equity Total equity Total Liabilities and Net Worth Common Financial Ratios

 

 

40,000

40,000

40,000

40,000

91,000

63,000

 

 

Debt Ratio (Total Liabilities/Total Assets)

0.56

0.25

Current Ratio (Current Assets/Current Liabilities)

0.63

2.67

(15,000)

35,000

Working Capital (Current Assets − Current Liabilities)



BUSINESS BASICS

93

or provide financial support, these ratios indicate how solvent the business is, how likely it is to survive, and possibly how efficiently resources are being used. The ratios can be used to compare year-to-year performance, compare the financial performance of your organization to others of similar size and operations, and to demonstrate the financial health of the organization in applications to receive financial resources from lenders and others.11 Summary Comparison of Balance Sheet, Income Statement, and Cash Flow Table 3.5 provides a comparison of balance sheet, income statement, and cash flow. Table 3.5  Comparison of balance sheet, income statement, and cash flow Statement type

Time window

What it shows

Balance Sheet

Snapshot in time

What a business owns and owes

Income Statement

Period of time leading up to the corresponding balance sheet

Operating activity, in terms of • Revenue, regardless of whether fees and reimbursements have been collected yet • Expenses, regardless of whether they have been paid for yet

Cash Flow Statement

Period of time leading up to the corresponding balance sheet

• Cash going in and out to run the business • Sources and uses of cash

These statements can show you early warning signs that may help you recognize opportunities for you and your team to help your organization run better to improve its financial performance and service capacity. You might lead your team to find ways to increase revenue from billable services, or to reduce expenses by streamlining work processes and consolidating unneeded steps or supplies, or by documenting your work with patients more effectively to increase the speed and full value of insurance payments received. Being proactive helps you and your team increase and demonstrate your value to the organization. And you need to be aware

94

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

ahead of time of financial challenges likely to lead to requirements for increasing productivity and efficiency that will affect your team.

Recommendations for Successful Financial Management Now that we have looked at local budgeting and financial statements for the overall organization, let us synthesize what you have seen to highlight key points and formulate some recommendations. Review Reports and Data Make sure you understand the source of data and calculations that affect and appear in your budget. You should continually examine the variances in your operations, through the ongoing operating statements produced by your accounting department, to understand and plan for changes and differences between what was expected and what is happening. In health care, there can be many shifts and changes in funding models and payor sources, sometimes without a lot of prior notice. In our earlier budget example, it looks like something is changing in either the insurance enrollment of the patients served in this clinic, shifting some from private insurance to government-funded programs such as Medicaid, or there could be shifts in the number of patients being served, or other contractual changes that affect how much the organization gets paid for serving patients. Be aware of the difference between favorable and unfavorable variances. When revenue is higher than budgeted, the variance is favorable, but when expenses are higher, that variance is unfavorable. Likewise, lower revenue is unfavorable variance and lower expenses are favorable. As we saw in our closer look at variance above, positive or negative numbers for individual accounts do not tell the whole story; they must be considered in the context of what the numbers represent, how they contribute to the bottom line, and in alignment with organizational operations and goals. Do not wait for once-a-year budget processes to track what is ­happening—make it a practice to review financial reports and data at least as often as once a month, watch trends and changes, be sure you understand how reported information is calculated, and ask questions.



BUSINESS BASICS

95

It is important for you to understand clearly what assumptions are made, what is included (and not) in the totals you see so you can focus on the right issues, be proactive in making needed improvements, and request corrections or changes if needed. Understand Budget Drivers and Where They Are Tracked For example, a major driver of oncology income is the volume of chemotherapy services. If this revenue from chemotherapy is reported in the Oncology Division’s budget, that division would look very profitable. If, instead, that revenue is reported in the overall hospital budget, then the Oncology Division would appear to be incurring more cost than the revenue it generates, which might make it vulnerable for reduction in its resources. As another example, your team might deliver initial clinical assessment or emergency treatment services that are not fully reimbursed by payors for the true cost, so it could appear that your team is operating at a loss, when your team’s activities are actually enabling later revenue generation through other services such as surgery or other high-cost treatments that generate revenue for the organization. Looking at statements and reports for the overall organization results, and other tracking areas you may be able to request access to, can help you maintain awareness to explain or quantify the value your team’s work contributes to the organization. Contributions and Alignment Even if your team does not generate revenue directly from its activities, or the revenue it contributes to producing is tracked somewhere else in your organizational budgets, it is essential that you understand how much you and your team are expected to contribute to revenue production, how much money has been allocated for your team to operate, and how it is being spent. Suppose you are responsible for an administrative or clinical support function such as quality, outcomes evaluation, employee training, or compliance that is necessary to the organization’s operations but does not provide any billable services to patients directly. For example, your team

96

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

might perform analysis of clinical outcomes, for which your team might not accrue any payment directly, but the resulting information confirms the value of the organization’s treatment services, which helps the organization attract more contracts and funding. When you understand the contributions your team is making to overall operations and financial health, you might request realignment of revenue and expense tracking to provide more accurate visibility and to support you in managing your revenue and expenses effectively, but you might not be able to influence accounting practices for allocation and reporting to the extent you would like. Thus, it is helpful for you to understand how your team’s activities support the overall financial health of the organization. The earlier section on big picture financial health will help you understand the bigger picture and how to use information about the organization’s finances. Manage Reasonably and Spend Responsibly: Avoid Hoarding and Frivolous Spending! Track and manage your spending throughout the year. Be reasonable and responsible to sustain your team’s work. Remember, as a manager, it is your job to ensure that your team has the tools and resources needed to do the work and achieve expected results. Spend what is necessary, and be a prudent steward of the organization’s money. Avoid delaying needed expenditures too long and ending the fiscal year with remaining funds that you should have utilized throughout the period. Be responsible, but do not hoard and deny access to available funds throughout the budget year for the things your team truly needs; such practices can lead to panic-driven, ineffective spending at the end of the budget year when managers realize they need to use money that was allocated in a current budgetary year or lose access to the money until the next budget cycle. This can make you look frivolous and irresponsible in your spending. Another danger of waiting too long to spend your available funds occurs if your organization develops its next fiscal year budgets using year-end expenditure projections from what has been spent prior to the last quarter. Your apparent frugality can set an invalid expectation for what you actually require to run your team effectively in a full fiscal year cycle.



BUSINESS BASICS

97

Recognize Quarterly and Seasonal Variation Do not assume that every quarter is like the prior one. Be aware of seasonal cycles and other variations that affect expenses or revenue. For example, flu season and the start of school years can add expense to stock extra medication for vaccines. Unexpected outbreaks of infectious diseases can increase service demand that results in extra overtime or temporary staffing, but might also generate additional service revenue. On the other hand, demand for service can also decrease based on school year cycles and weather. Kids may be less inclined to come in for treatment during school holiday periods; kids and adults might avoid coming in during cold and inclement weather periods. On the expense side, conferences and external continuing education activities for staff might occur at certain times of year and add to expenses during those periods that are not repeated in other periods. Generate Insights for Further Learning As you look at how your organization is performing overall, you will gain insights, formulate questions about the value of your team’s contributions, and strengthen its alignment with the overall organization. This can be the perfect opportunity for you to get to know the members of your accounting department who can help you get and interpret numbers and information to master the skills to be an effective manager of the business of running your health care teams!

Applying Financial Principles in Clinical Practices Now you have seen how to organize, track, and manage the financial resources that fuel the work of your team and organization. As we wrap up this chapter, let us reflect on how this impacts our clinical practices to benefit our patients. Here are some examples from other leaders in clinical settings. Business Goals: Less Negotiable than Shared Patient Outcome Goals When I asked my old boss, Carl Clark, MD, CEO of the Mental Health Center of Denver, about medical education and how it matched with

98

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

running the business of health care, he explained that in clinical training, there is emphasis on engagement, treatment options, and negotiations. “You hope that you and your patient have the common goal of good health outcomes. Business goals, on the other hand, are not so negotiable. You need to make sure the right functions of the business are in place, in service to the operations of the business.” He explained the importance of understanding the levers and their effects on financial effects. For instance, understanding how to work with your organization’s cycle of payments to its vendors could impact the organization’s cash flow.12 Cash Flow’s Positive Effects on Services When David Dobrzykowski, PhD, was working as a health care executive, he was able to free up cash flow, which allowed him to open up three more facilities for his organization.13 Another organization with a large annual budget found that if it could delay payments to its vendors from 30 to 31 days, it could increase the organization’s cash on hand by almost a quarter of a million dollars. Lisa Potter, MHA, MBA, explained that implementing consistent practices for collecting patient co-pays and fees up front improves cash flow and reduces expenses from having to pursue collections later.14 Generating cash can fund the resources needed to focus on delivering more and better care for patients. Mastery of Business Principles for Financial Well-Being Wellness practitioners who are running their own businesses know that their financial well-being depends on their mastery of business principles. Cherie Sohnen-Moe (2016), a massage therapist in private practice, explains how private practitioners need to know how much money their practice requires to start up and operate in the first and subsequent years. They identify the income they need to earn, the revenue they expect to earn from specific sources (direct services, training, consulting, workshops, classes, other products and services), and the costs they need to cover (rent, utilities, supplies, salaries, administrative services, marketing, insurance, etc.).15 Their mastery of the business components sustains the effective and enduring operations of their health care practices.



BUSINESS BASICS

99

Julie Artigliere, PhD, runs a speech and voice therapy practice. Her costs of operating include paying for office space and administrative services such as patient scheduling and billing services. Her revenues vary with the rates paid by different insurance companies that cover the services to patients. For example, physicians’ diagnoses can impact the rates paid for patients covered by Medicaid and Medicare, and she has a separate contract with another insurance company that she bills directly and collects different rates, which changes her revenue and expenses for services to those patients. Setting appropriate wages for provider staff gets complicated because there isn’t one consistent hourly rate earned in services for all patients.16 Understanding the factors that contribute to the bottom line ensures continuing financial health that fuels the resources that support the continuing practice. Healthy Finances Enable Healthy Patients As these examples show, minding the money and finding efficiencies can help the organization do more with its resources. Dixie Casford, LPC, MBA, Vice President of Acute Care at Mental Health Partners, summed it up vividly as, “When we look at how to allocate funding and resources, we can put a face to every dollar.”17 In other words, we need money and other resources to continue to operate so we can provide our patients with the health care services they need. Joanie Gergen, CRCR, Director of Revenue Cycle at Mental Health Partners, pointed out that implementing fee collection policies was helpful to the organization’s clients, too, in setting expectations for treatment and connecting with the organization’s goal to ensure positive client experiences.18 Thus, managing the business aspects of our health care organization ensures the financial health of the organization to support service availability and effectiveness for patients.

Chapter Summary and Key Points Now that you have learned about key financial principles that drive your organization’s business, it can help you plan and manage the resources on your team, and point you toward areas where you and your team

100

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

can impact organizational success. We worked through a budget example that illustrated the development of a budget based on the previous year’s operations and projections for the next year. You have seen illustrations of three key financial statements: a balance sheet, income statement, and cash flow statement. You learned some key financial definitions such as profit and fiscal year cycles, looked at relationships related to profit and loss and the organization’s cash flow, and saw examples of how that can help you serve your patients. Key Points: 1. Many health care organizations operate as “not-for-profits,” existing to serve the needs of their communities rather than generate profits for any groups or individuals. 2. Regardless of profit motive, every health care organization needs to generate enough revenue to cover the expenses of running the organization and serving its patients. 3. The organization’s balance sheet shows its assets, liabilities, and net worth at a point in time. 4. The organization’s income statement, also referred to as a profit-and-loss statement, reports what the organization received (income or revenue), and what it spent (expenses and costs) over a specified period of time. 5. The organization’s cash flow statement shows the organization’s ability to pay current expenses, particularly as a function of the amount of money owed to an organization for services and goods that have already been provided and the length of time it takes to receive payment. 6. The balance sheet, income statement, and cash flow statements shed light on an organization’s earning and spending that drive budgeting and buying decisions. 7. Your budget helps you plan and allocate the resources that are needed for your team to do its work. 8. You can track and manage important parts of your managerial performance by reviewing your team’s budgeted and actual financial activities. 9. Organizations operate on fiscal year cycles, which drive your planning and budgeting activities. Know when the fiscal year begins in



BUSINESS BASICS

101

your organization—it may be at a different time of year than the January 1 start of the calendar year. 10. Track and manage your spending throughout the year. Be reasonable and responsible to sustain your team’s work. Avoid delaying needed expenditures too long and risking loss of the funds when the fiscal year ends.

Learning Activities for This Chapter Here are some questions to consider that can help you understand the business aspects of your organization and your managerial role in it. This will help you identify what you need to know, where you can find out, and think about how your knowledge in these areas is beneficial to your team, organization, and your direct success as a health care manager. 1. What is the mission of your organization? Why does the organization exist, what purposes does it serve, and who benefits? 2. For financial purposes, how is your organization classified? What are the implications? Even in not-for-profit, mission-based organizations, keep in mind the saying, “No money, no mission!” What does this mean in the context of delivering health care services in a not-for-profit health care organization? 3. What is charity care and how much of your organization’s services are in this category? 4. Do you believe that minding the money is someone else’s job? To what extent? How much of the responsibility is yours? 5. In your organization, who keeps track of the financial health and operational details of revenue and expenses? What resources and information do they have that can help you manage your teams’ budgets effectively? 6. How do you and your team impact the financial health of the organization? What do you contribute to: a. Income (also referred to as Revenue), and how—through what activities? b. Expenses—consider the costs of operating your team, and things your team can do to manage costs.

102

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

7. Grants can help fund new clinics, programs, and research. Should you always pursue and accept grant funding? Why or why not? What is your organization’s history of successfully applying for grants and utilizing the funding? For more information on grant funding, see Appendix A. Here are some activities to help you apply these subjects to your business management responsibilities in your organization. 8. Get copies of your team’s budget from the previous and current fiscal years. What has changed and what factors contributed to changes in revenue, expenses, and staffing? 9. Find out from your accounting department where to get operating statements or other available information that shows you year-to-date financial performance relative to your budget. a. If things continue at the current rate of revenue and expense accrual, what are your projections for year-end results (at the end of your fiscal year)? b. Are there variances and trends you see that signal there are actions you need to take now? c. To be more effective in your budget and financial performance, what things should you Start, Stop, and Continue doing?

CHAPTER 4

Where Do You Go from Here? Keeping the Motivational Fire Burning Chapter Overview In this final chapter, we wrap up your journey toward being an effective health care manager. We shift from the skills you have been learning in earlier chapters to do your job now, consider how you sustain your momentum, and look ahead to your future. We will look at how you balance areas of your life and renew yourself, sustain your success, address challenges that signal the need for changes, foster your growth and development, benefit from others helping you to improve, move from success to significance, and continue to fuel your passion for the work you do. Topics in this chapter: • Highlights of your journey to here • Leaders who are burning bright • Balance and renewal • Sustaining your success at work • Your growth and improvement • Outward and onward! • Chapter summary and key points • Learning activities for this chapter

Highlights of Your Journey to Here As you have read through this book, you have heard from many different people who participated in interviews and conversations to share their

104

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

experience and advice about working in health care management. They come from many different roles, specialized training and practice focus, and levels of responsibility, and they represent a wide range of styles, preferences, goals, and interests. All of them demonstrate their passion for the work they do and caring for the lives they touch. Many were fortunate in finding organizations to work in that aligned with their interests and supported them in their growth for long and satisfying careers there. Others found new ways to apply their valuable capabilities in new settings and organizations. You have seen recommendations and examples for building relationships at work, organizing your activities, taking action, initiating conversations, resolving conflict, developing leadership in yourself and others, and building your business management skills. Now we will look at ways to sustain all the progress you have made, so you can continue to build on your momentum and leverage the strengths and skills you brought with you and continue to develop in your work as a manager. At this point it could be helpful for you to pause and identify which recommendations from interviews and sections of both volumes of these books are timely for the activities and issues you are working with right now. Then, consider how you might apply the recommendations in ways that fit you and the organization and situation where you are working. Think about what keeps you interested and engaged in your work, and how your contributions have contributed to success for you, the organization, patients, and the community you live in.

Leaders Who Are Burning Bright What motivates you and inspires you to stretch and attain new goals? To help you envision possibilities for your road ahead, let us consider a few examples from senior leaders who have worked in health care for many years. These represent some of the people I interviewed who continued to thrive and evolve over several decades. Dixie Casford, LPC, MBA, started as a clinician and was offered a supervisory role in 2 years. She continued to learn after completing her clinical master’s degree, earned an MBA, and enjoyed the opportunity to apply her analytical and business skills in helping others understand



WHERE DO YOU GO FROM HERE?

105

important aspects of running the clinic.1 She advanced in her current organization from a Director to the position of Vice President by using her clinical skills to fill in staffing gaps and applying her growing business skills to continuously improve clinical operations. As funding streams shifted and required new approaches to operating efficiency, she stepped in to fill organizational gaps, as she is completing further education in legal and compliance issues to contribute additional value to her organization in her current role.2 Barbara Becker, PhD, JD, became a nationally recognized leader in suicide prevention. It started as a personal interest because there were several suicides among her daughter’s friends and classmates. She got involved in grassroots programs, received encouragement and support at top levels of her organization for her community work on this. With her varied background and experience, she needed change and challenge. She advises seasoned, ongoing managers to always be open to new ideas, to not become complacent, to know yourself, figure out what gets you excited, and talk to others about how to make that happen.3 Jim Monk earned his DDS in 1984, and then spent 29 years running his own dental practice. He had some coursework in basic, rudimentary accounting in dental school. He learned Human Resource management in his own dental practice. Later he attended classes on HR and hiring as part of required continuing education, self-directed so he could choose what he needed. He learned many of the business skills he needed to manage his business and perform some tasks himself, such as payroll and some bookkeeping, to keep his overhead costs low. He sold his dental practice, partially retired, and now works for Boulder County Dental Aid, where he understands the funding and billing complexities of working with Medicaid insurance. He values the teamwork among the staff required to manage funding. Jim is very interested now in coordination of care and whole-person health across health care disciplines, such as the role of dentistry in cancer prevention and early detection. Medicine changes slowly, he said, and we are learning more about inflammation and its impacts on health, and the role of oral health. Reading health books on food and nutrition helps him continue to learn and fuel his interests in service to the health of his patients and the community.4

106

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Roy Starks, MA, worked in psychiatric rehabilitation since the 1970s and retired from a successful and impactful career at the Mental Health Center of Denver (MHCD), where he worked for 28 years. A big motivator for him was helping people get better and live more meaningful lives. He has always focused on strengths rather than weaknesses. He built a strong reputation in his profession, earned a leadership position as chairperson of the board of the Psychiatric Rehabilitation Association, and published in its journal on groundbreaking work he led in his organization. He emphasized the importance of reporting to a CEO who is aligned with what you believe. Alignment with the mission of the organization was an important motivator for Roy. His boss and organization supported Roy in creating new opportunities and growth for him and his teams that contributed to the organization’s success in living its mission.5 We will see more in this chapter about continued growth and sustained enthusiasm like what these leaders demonstrate.

Balance and Renewal The Importance of Self-Care Stephen Covey (1989) provides in his book, The 7 Habits of Highly Effective People, a parable of a man who complains of exhaustion because he is too busy sawing to sharpen the axe. Covey identifies four dimensions of your nature that need to be renewed and balanced to preserve and enhance “the greatest asset you have—you.” These dimensions are: • • • •

Physical: Exercise, Nutrition, Stress Management Social/Emotional: Service, Empathy, Synergy, Intrinsic Security Spiritual: Value Clarification and Commitment, Study and Meditation Mental: Reading, Visualizing, Planning, Writing

He explains that “the single most powerful investment we can ever make in life [is] investment in ourselves, in the only instrument we have with which to deal with life and to contribute. We are the instruments of our own performance, and to be effective, we need to recognize the importance of taking time regularly to sharpen the saw in all four ways.”6



WHERE DO YOU GO FROM HERE?

107

Covey (1989) describes your spiritual dimension as “your core, your center, your commitment to your value system. It’s a very private area of life and an extremely important one. It draws upon the sources that inspire and uplift you and tie you to the timeless truths of all humanity. And people do it very, very differently.”7 Many interviewees mentioned self-care as a necessary skill. For some, this involves time alone to reflect or create. For others, being with other people or physical activity is necessary and energizing. Be aware of what works for you. Focus on activities that feel refreshing and help you feel calm, energetic, happy, well, or in control. The important thing is that you find what works for you and feels rejuvenating, and do it! This includes both doing things that are fulfilling in your life away from work, as well as what keeps you functioning well at work. Your Purpose and Values Think about why you are doing the work you do. Jim Donovan (2014) recommends you consider how your work brings you satisfaction and how you are serving humanity. “Regardless of how important or menial you feel your work is, it is an essential part of something bigger. When you understand this you will find it easier to derive pleasure and meaning from your work. You will feel better, and, as a result, be happier. You may even be promoted!”8 Many people working in health care have expressed the purpose of helping people live better, healthier lives. Perhaps you would state other aspects of your purpose, such as helping to develop others to provide effective care and treatment, developing and sharing knowledge that contributes to population health, or improving health and happiness in your community. Your purpose is closely related with your values. Donovan (2014) explains how alignment with our values contributes to our happiness and satisfaction with our work. “By values I mean those principles and qualities that you hold dear . . . such as love, success, compassion, freedom, contribution, adventure, and security . . . . Our happiness or satisfaction in any situation depends on our most important values being met.” “If you align your life and work with your unique order of values, you will be happier and more productive.”9

108

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

What Makes Life Worthwhile? An important way to take care of yourself and keep your life balanced is to pay attention to your overall well-being. The Gallup organization conducted extensive research to identify the five elements that are essential for a thriving life. These are things we can do something about to improve our lives. As described by Tom Rath and Jim Harter (2010), the five elements of well-being are summarized in Table 4.1.10 “When we strengthen our well-being in any of these areas, we will have better days, months, and decades. But we’re not getting the most out of our lives unless we’re living effectively in all five.”11 So, while career is vitally important for you to thrive, you need to pay attention to all five elements to continue to sustain yourself in work and life.

Table 4.1  Five elements of well-being Element

Definition

Description

Career well-being

How you occupy your time, liking what you do every day

Sense of purpose and looking forward to what you do, with opportunities to do things that fit your strengths and interests.

Social well-being

Having strong relationships and love in your life

Having close relationships that help you achieve, enjoy life, and be healthy, and networks of people who encourage growth and development, accept you for who you are, and treat you with respect.

Financial well-being

Effectively managing your economic life

Managing your personal finances well and spending your money wisely for satisfaction with overall standard of living. Financial security to eliminate stress and worry, being able to do what you want and spend time with people you like to be around.

Physical well-being

Having good health Managing your health well. Exercising regularly, and enough energy making good choices of food, getting enough to get things done sleep, to feel good, think clearly, sustain energy throughout the day.

Community well-being

The engagement you have with the area where you live

Feeling safe and secure where you live in a home that meets your needs and a community where you can feel pride that it is headed in the right direction. Wanting to contribute and be involved in your community.



WHERE DO YOU GO FROM HERE?

109

Sustaining Your Success at Work According to Marcus Buckingham (2005), “Sustained success means making the greatest possible impact over the longest period of time.”12 He believes that having a great impact requires that: 1. You apply your natural talents and enthusiasm to become good at something. 2. You stay good at something and more than likely get better. Getting better, particularly in today’s rapidly changing work environment, requires that “you be resilient, flexible, open to learning, innovative, confident, optimistic, and all the while, sufficiently devoid of stress to maintain your energy for the long haul.”13 Sustaining in the Face of Boredom, Unfulfillment, Frustration, Draining Experiences Marcus Buckingham (2005) identifies some things that challenge our sustainability in our jobs, and offers remedies. Some challenges and remedies for sustaining in our jobs is provided in Table 4.2. Buckingham advises, “The longer you put up with aspects of your work that you don’t like, the less successful you will be. So, as far as you are able, and as quickly as you can, stop doing them, and then see what the best of you, now focused and unfettered, can achieve.”14 He reminds us that it is always our responsibility to make the adjustments that allow us to sustain our highest and best contributions at work. “The more skilled you are at this, the more valued, and fulfilled, and successful you will become.”15 Do You Really Want to Be a Manager? Recently, when I told an MD I met in a social setting that I was writing this book, her eyes widened as she said, “I love taking care of my patients! I have no background or interest in doing administrative things. I can’t imagine being a manager or why I’d want to do that!” She is like many others who are clear about the kind of work they choose to do.

110

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Table 4.2  Challenges and remedies for sustaining in our jobs Challenge

Description

Remedy

Boredom

“Your deep interests are not engaged. You may enjoy the activities themselves, but the content leaves you cold.”a

Change to a different role.

Unfulfillment

You enjoy the activities, and may perform them well, but they might not engage your values, or might require you to compromise your values.

Change to a different job in a different organization.

Frustration

Your interests and values are both engaged, but your strengths are not being used.

Find and propose new ways to apply your ideas to use your strength in a redesigned role. “Find a tiny stream in which your strengths can flow, and carve it into the Mississippi.”b

Feeling drained

“Your job requires you to have strength where you have weakness.”c You are expected to do things in ways that are unnatural for you, which is a draining experience.

1. Find someone else to do what is draining to you. This could involve delegation or forming partnerships. 2. Find an aspect of the activity that brings you strength, or find a higher purpose aligned with your values, and focus on that. Last resort, use other interventions as shown for challenges above: 3. Leave the role 4. Adjust the role

a

M. Buckingham. 2005. The One Thing You Need to Know (New York, NY: Free Press), p. 263. M. Buckingham. 2005. The One Thing You Need to Know (New York, NY: Free Press), p. 272. c M. Buckingham. 2005. The One Thing You Need to Know (New York, NY: Free Press), p. 272. b

Other clinically trained people move to management roles, still value seeing patients, and are reluctant to give up that part of their work. They try to fit in both types of activities, but feel they cannot give patients the attention they deserve when so much of their time and energy is focused on administrative tasks. They may realize that what they truly love to do is to work directly with patients, so they feel that the administrative requirements of their management jobs are unwelcome burdens that weigh them down or distract them from their most important focus. If this feels familiar, it may be time to honestly ask yourself, do you really want to be a manager? Why?



WHERE DO YOU GO FROM HERE?

111

Bill Milnor, MA, my colleague at MHCD, has hired, promoted, and coached many new managers who had been clinicians. He advises new managers to dig into what it means to be a manager, and tells them, “Your identity is going to change . . . . What do you know about management?” He has noticed that there are managers who might be happier as clinicians.16 As he explains in an Executive Briefing from Open Minds, I have hired many managers out of the clinician pool and have paid very close attention to their specific motivations, and I want to believe that most hiring processes are similarly informed. What I pay most attention to is how enlightened a candidate is to what management is as a discipline and practice regardless of their previous experience, clinical or otherwise. Succeeding that, I look for the potential they possess in talent and interest toward management. I can recall a couple of excellent clinicians who I promoted to managers, of course, after competitively interviewing, that after a period of time figured out they preferred to be clinicians. They were becoming very good managers but were not feeling the satisfaction. I regularly say that one has to “really want to be a manager.” It’s really not hard to spot a clinician in manager’s clothing although sometimes it is quite hard for them to see that themselves.17 As you have been developing more understanding of what managers do, you may be discovering more about how well suited and interested you are in developing the skills required to be successful as a manager. Of course, there are challenges in learning new skills required for any new roles and responsibilities; you have worked your way through them to earn your clinical degrees and credentials. If you feel some doubts about whether you are in the right role, it may be time to reconsider your values, interests, and what will sustain you. Many other managers have moved back to clinical roles and felt much more satisfied with their work, and this might turn out to be the appropriate path for you, too. Be honest about what is and is not working for

112

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

you. The previous section can help you explore and choose an appropriate resolution for your discomfort. Here are some recommendations to help you sort out this specific decision of whether to move to a direct clinical position or continue as a manager. Give Yourself Time to Adjust and Learn As repeated by many people I interviewed, moving from clinician to manager is a big change that will stretch you in new ways. There is a lot of learning required to become a competent manager. Be patient, do not expect to know everything right away. Your day-to-day routine, and perhaps even the environment, will be different and will require some time to adjust and feel comfortable in a new setting, different tempo, and new procedures to master. Expect some discomfort as you adjust for the first several weeks or months. Review What You Really Want to Accomplish at Work Think about where you see yourself having the most impact. Consider how your particular skills and interests help patients and contribute to healthy communities. Some ways to do this are by applying your clinical knowledge to help develop other clinicians, or to help shape the overall health care system in your organization or at the broader community level. These are things you will be particularly focused on as a manager. On the other hand, if you see your biggest contributions and primary satisfaction coming from the clinical work you do directly with patients to provide care and treatment, then perhaps you really would be happier and more effective being a clinician rather than a manager. What Other Activities Can You Emphasize or Add? You spent a lot of time and effort in your clinical education and training. Keep in mind how valuable this is as you help other clinicians learn and grow and as you make decisions that support effective clinical operations in your organization. Even if you are currently managing a function that does not provide direct clinical services to patients, you are using your



WHERE DO YOU GO FROM HERE?

113

clinical knowledge to support key service-oriented goals for the organization and to collaborate with others. Other activities you might be able to add include mentoring or supervising other clinicians. After I obtained my clinical license and was managing several administrative teams that supported but did not provide direct clinical services, I let clinical program managers know that I was available to provide clinical supervision to their new license-eligible clinicians who needed supervision in my clinical discipline. This led to several satisfying opportunities for me to apply my clinical knowledge to help new clinicians build their clinical skills and credentials. There could be other opportunities, or even requirements to maintain clinical licensing, for clinically trained managers to provide direct care and services to patients. For many people, this works very well when the time is clearly allocated and protected to see patients and provide high-quality care. This requires the support of the manager’s boss and the organization to honor the time commitment and protect clinical scheduling from being overridden by frequent competing demands for administrative time. If providing direct clinical care is of high value to you but your organization does not support the time commitment for you to allocate to this during regular working hours, then you might need to think about moving to a different role in your organization, or to an organization that allows you to balance and fulfill your needs in both areas. Or could you spend some time outside of work providing clinical services as a volunteer or in a separate practice? Sections below show you how to get some new experiences and how to use feedback from others to help you land where you will thrive. If you are seriously pondering, “Do I really want to be a manager, or would I rather be a clinician?” you can apply the learning activities at the end of this chapter to this question. The activities can help you gain clarity about this, as well as other areas for you to explore about your focus and direction. New Experiences and Changes Do you need some new experiences or changes in your work? Cherie Sohnen-Moe (2016) advises that you recognize and prevent boredom

114

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

that can seep in when an overrepeated rhythm turns into a rut. Find and engage in work activities that motivate or inspire you and can help you grow. This could require that you move into a different role or find new activities to enhance your enjoyment and motivation in your current role. Boredom or dislike of repeated routines came up in some of our interviews. Some people reported that after many years of clinical practice, they felt they had mastered the needed skills and were looking for new challenges. In another case, a person still enjoyed working in health care, but was not enjoying being on-call and performing treatment activities he had learned in his years of clinical training and which he no longer found interesting. In these cases, people found great rejuvenation in new roles that they find fresh and interesting. Fred Michel, MD, remarked that after 10 years, direct medical practice can get boring, particularly if you are not learning new things. Administration, on the other hand, he finds fresh and interesting. He is never bored because he feels he has not mastered it yet. Some people pick up interesting ideas through reading. For example, Michael Sullivan, MD, enjoys biographies of successful people such as Abraham Lincoln, Steve Jobs, and others to consider what made them successful. Others stories can give you inspiration and motivation to discover ways to thrive in your current role, or to move to something new. He recommends embracing change rather than avoiding it. “At some point in everyone’s career, go back to school or get some kind of training for deep thinking to re-engage the brain and rejuvenate,” Dr. Sullivan advises. This is above and beyond required continuing education that is an expected part of the job. Formal training may be necessary for learning the language of business, especially in finance; course work can be online. Even with soft skills there is a science to it and common language. “Leaders aren’t just naturally born, it requires working at it. Get involved! Seek opportunities, join committees, champion clinical improvement projects.”18 Look for ways to contribute in your current role. It is better to shape what you are working with and create a brighter future rather than struggling to manage in an environment that is not working.19,20 Volunteering to participate in special projects, committees, or workgroups can provide avenues for you to influence the changes you would like to see.



WHERE DO YOU GO FROM HERE?

115

Adding new experiences and activities can be invigorating to you and your career. When David Bachrach, MBA, FACMPE/LFACHE, works with an internal candidate who was not chosen for a promotion, he recommends the person compare his curriculum vitae (CV, or resume) to that of the successful candidate and suggest ways to overcome some perceived limitations. If the person only has experience in one place, would other assignments, such as a visiting professorship, help expand his experience?21 Cherie Sohnen-Moe (2016) recommends, “Keep in mind that any career has its ups and downs. The key is to recognize the difference between a natural phase and a downward spiral. Step back and objectively evaluate the situation. Determine why you’re encountering boredom and what might work best to remedy it. After you’ve assessed the situation and brainstormed possible solutions, discuss the issue with an advisor. Getting feedback from a trusted advisor can often shed new light on a challenging situation.”22 Mentoring and Guiding Others Early chapters, particularly in Volume I, and many interviewees explained the value of having a mentor to guide your own growth. In their book, One Minute Mentoring, Ken Blanchard and Claire Diaz-Ortiz (2017) explain the mutual benefits of mentoring relationships. “Your mentoring relationship will bring you new perspectives and ideas. Whether you’re a mentor or a mentee, stay alert and open to the new opportunities that arise through your mentoring experience.”23 Sharing your experience with others can bring new insight and meaning for yourself. For example, Jean Rosmarin, PhD, finds that conducting training classes is “renewing, it reminds us why we do the work.” Training others, either in classes or sharing your skills and experience in supportive interactions, can provide you with growth and renewal. Jean also has run a successful private psychotherapy practice for many years and offers mentorship to others in opening their own practices.24 There are various ways you can mentor others, within your own organization or in other arenas. Stay open and watch for ways to do this. This reminds me of experiences I appreciate from when I was an executive leader at MHCD. MHCD began to focus strategically on building our

116

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

community relationships, so we belonged to several local chambers of commerce and participated in their social activities. Attending the networking events at several chambers felt inspiring and invigorating to me because I enjoyed meeting new people and discovering new resources for our organization. It was fulfilling to engage others in supporting MHCD and attending our events in the community, and to form other friendships. New relationships led me to join the board of directors of another nonprofit organization. Joining boards of other organizations can provide a valuable avenue to mentoring leaders in other organizations while you learn new skills to contribute to your community or profession. As MHCD increased our efforts to extend our organizational reach into these chamber groups, I joined an MHCD planning team of senior leaders. We organized and conducted training seminars to engage more of our managers and staff in learning networking skills. Sharing my experience in representing the organization in networking situations brought me new insights from working with several managers and other staff on our clinical teams to support them in becoming chamber ambassadors. They brought new perspective from their roles and work at other locations that helped me learn and grow as a senior leader. Mentoring connections can arise in several ways. Here are some examples: 1. Mentoring connections can arise within relationships you already have with people at work or other areas of your life when they seek you out for help or advice. 2. You may find yourself working on projects, either at work or in activities in outside organizations where you volunteer or participate. There you could develop relationships with others who benefit from your wisdom and guidance. 3. People in your social and professional networks might recommend that others contact you when they are seeking guidance from someone with your experience and abilities to help them. 4. You can be intentional in seeking others to mentor by spreading the word within your network or volunteering for organized mentoring activities in your local community, alumni associations, professional societies, and other avenues.



WHERE DO YOU GO FROM HERE?

117

Your Growth and Improvement Carol Dweck (2006) explains that great leaders have a growth mindset. “They are constantly trying to improve. They surround themselves with the most able people they can find, they look squarely at their own mistakes and deficiencies, and they ask frankly what skills they and the company will need in the future. And because of this, they can move forward with confidence that’s grounded in the facts, not built on fantasies about their talent.”25

Confront the Facts, and Keep Faith that You Will Prevail Jim Collins’ (2001) book, Good to Great, was mentioned frequently in interviews as offering valuable lessons for leaders. Collins dedicates a chapter to confronting the brutal facts yet never losing faith. He provides the Stockdale Paradox as a powerful illustration, drawn from his conversation with Admiral Jim Stockdale. Stockdale survived as a prisoner of war for 8 years during the Vietnam War, under abominable conditions with no release date in sight. Yet he did everything he could to create conditions that would help the prisoners under his command survive unbroken, and he never doubted that he would get out. When Collins asked Stockdale which prisoners did not make it out, Stockdale explained that it was the optimists, who counted on getting out at set points in time, and after they lived through numerous dates coming and going without their release, they eventually “died of a broken heart.” Collins frames the Stockdale Paradox as, Retain faith that you will prevail in the end, regardless of the difficulties, AND at the same time, Confront the most brutal facts of your current reality, whatever they might be.26 Collins explains how the great leaders he studied focused on just the few things that have the greatest impact because they “operated from

118

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

both sides of the Stockdale Paradox, never letting one side overshadow the other.” While it can be challenging for you to manage in the face of rapid changes in health care funding and requirements, you can choose to focus on the important things you, your team, and organization perform that impact the health of your patients and well-being of your community. You can continue to develop your management skills and support your team members in improving clinical skills and developing their leadership skills. Together, you can find better ways to do things to satisfy requirements for organizational efficiency, high service value, and excellent clinical outcomes. Accepting Help for Improving In their book, Tribal Leadership, Dave Logan and John King (2008) consider how leaders can advance along with those they lead to the highest stage that maximizes organizational potential and innovation. They caution against leaders relying too much on only themselves. “Effectiveness is capped by their time, which is a limited resource. The more the person can accept help from others, the more he will see that help from others is not only helpful but necessary to his becoming a fully developed leader. Once he begins to form strategies that rely on others, and in which others rely on him, he will have taken a big step.”27 This is about more than just delegating specific tasks, which we examined in Volume I. This is about your development and improvement. Let us look at how you use feedback and your own coachability for improving your skills and capabilities. Accepting and Following Up on Feedback Kay Martin, LCSW, has been a health care manager for over 35 years. She started off doing purely clinical work for 5 years, then worked as a program manager for 5 years, and recently retired as Chief Operating Officer at Solvista Health. She advises that you keep your focus, keep your heart, and recognize that you have a long career ahead of you. “Don’t take yourself too seriously,” Kay advises. “Be able to turn the lens inward to evaluate yourself and accept feedback.”28



WHERE DO YOU GO FROM HERE?

119

Accepting feedback requires humility and openness to accepting help from others. Some people I have talked with believe that their most valuable growth came as the result of feedback they received in formal reviews that may be described as 360-degree feedback. In such reviews, input is gathered from multiple perspectives of people who work with the person up, down, sideways, and could include the perspective of patients and customers. One of the managers I interviewed learned from this process that he needed to listen more to the people who worked with him. He made this a goal, practiced, and concentrated on improving his listening skills. You can improve by accepting feedback, acting on it, and checking back for other people’s perceptions of the results. As Marshall Goldsmith (2007) explains in his book, What Got You Here Won’t Get You There, “Follow-up shows that you care about getting better. Following up with your coworkers shows that you value their opinions . . . . Becoming a better leader (or a better person) is a process, not an event . . . . Followup turns changes for the better into an on-going process—not only for you but for everyone around you who is in the follow-up mix. When you involve other people in your continuing process, you are virtually guaranteeing your continuing success.”29 Another manager’s 360-degree feedback revealed that one person thought she needed to treat people more respectfully. She admitted that this feedback was unexpected and hurt initially. She reflected on it and realized that she might have developed some undesirable habits from emulating a boss she’d had who was known for his abruptness. She decided that if even one person felt that she was not treating people well, then she needed to address it. She brought all of the feedback to her team meeting to discuss and work on, and found that it raised awareness of how people were talking to one another and the effects they had on each other. Now her whole team is consciously working toward communicating more constructively, and this has strengthened the positive work culture of the entire team. Coachability In the words of Gary Markle, “Coachability sets [the] stage for performance improvement.” This means being open to change and using the

120

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

feedback you receive from your boss and others to help you improve and advance into roles and responsibilities you desire. For example, when a manager was told by his boss that one of the areas to concentrate on for improvement was to stand up and take a more visible leadership role in meetings, the manager stood up that same day in a meeting, and spoke from notes he had prepared.30 Author Marshall Goldsmith (2007) demonstrates how a coach helps him follow up on his important goals. His coach calls him every night and asks him a set of questions that he answers honestly. The questions include some things that are hard for him to do, that matter, and require discipline. Questions start with, • “How happy are you?” There are health-related questions such as, • “How many hours of sleep did you get?” • “How much walking did you do?” along with work productivity, • “How much time did you spend writing?” and questions about what he did that was nice for his wife and other family members. There are questions about behaviors that are getting in the way: • “How many times did you try to prove you were right when it wasn’t worth it?” • “How many minutes did you spend on topics that didn’t matter or that you couldn’t control?” Goldsmith believes that having someone else to help him follow up on his goals provides encouragement and input and helps him measure his progress. He suggests that if you do this kind of follow-up regularly with another person, that you will meet your goals for change.31



WHERE DO YOU GO FROM HERE?

121

Feedforward to Improve in the Future Goldsmith (2007) recommends the feedforward approach to engage others in giving you suggestions that help you change. Instead of focusing on reports of what you did in the past (feedback), feedforward elicits ideas on what you can do to improve in the future. Here is how it works. 1. Pick one behavior that you would like to change that would make a significant positive difference. For example, “I want to be a better listener.” 2. Tell other people what you want to change, in a one-on-one dialogue with each person. 3. Ask each person for two ideas about how you could do that in the future. The people you ask could be people you know at work, home, or family. Some of the best ideas could even come from strangers because they are not biased by what they have seen you do in the past. 4. Listen attentively and thank the other person. Do not judge or critique the ideas, just accept them as input. Feedforward is effective because: 1. It requires that you ask for other people’s ideas. 2. It brings out the best in others because they have the opportunity to be helpful to you. 3. People prefer to get helpful ideas for the future rather than painful criticism about the past.32 Remember, pick something that will really have an impact, something that is getting in the way of your performance or that will truly make a difference to your team or organization. Do not pick something to improve just because you know it is achievable!

Outward and Onward! Consider the impact you and your team contribute not only within your organization, but also in your community and in other settings where your skills and values contribute to these other missions. This could include volunteer work, professional societies, and other activities. Go beyond

122

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

just showing up at meetings and become an active contributor. Running for election or accepting appointments to officer positions in other associations or professional societies will help you establish valuable contacts that strengthen your professional and personal network, and can enhance your organizational and leadership skills. Several of the people I interviewed have experience and helpful suggestions about this. Success and Onward: To Significance and Impact Gene Dankbar, MS, MBA, of Mayo Clinic suggests showcasing a team’s work at conferences and helping them build an academic resume through research, publishing, and presentations about the results of projects you commission to improve areas such as patient turnaround and scheduling. For your own development, take on committee roles to build skills and find mentors. “A person looking to move up can build skills and contacts contributing to the community. Look for organizations in your community that may appreciate your help and give you the opportunity to learn new skills.”33 Several of the people I interviewed, and I have volunteered to review applications for grant funding with community foundations, and we have found the experience valuable for gaining more insight into what funders are looking for so we can better position future proposals for our organizations. Elvira Ramos talked about building pipelines of future leaders and succession planning. Encourage your employees to get out in the community to build skills. Toastmasters is a valuable resource for developing public speaking skills and getting practice. People who have participated often find it helps them in multiple areas of their lives, not only at work and volunteer roles but at family events too. The repeated practice can build confidence in speaking and leading more effectively. Fellowships, such as the Leadership Fellows program that Elvira developed and leads, helps its members build contacts and set goals that help them earn appointments to boards of directors or elections to public office, so the fellows are prepared to make significant impacts in their communities.34 Carl Cark, MD, always values learning something new. For the more experienced managers to sustain their passion, he advises, “Move from success to significance. An example is the Dahlia Campus that MHCD built



WHERE DO YOU GO FROM HERE?

123

with deep and meaningful engagement with the community, which initially didn’t want us, a community mental health center, in their neighborhood.”35 The senior leader who envisioned a welcoming campus that addressed comprehensive well-being needs for children and families in the community went out and developed relationships to build a base of community collaboration and philanthropic support that enabled her to attain her vision.36 And, Carl added, “The Sanderson Apartments were built to house long-term homeless people, who had been homeless 10 years or longer. Trauma-informed principles informed all components: the architecture, Denver Housing Authority, and others.”37 These projects demonstrate the power of moving from individual achievement to team collaboration onward to impactful significance in the community. Annette Canon, PhD, MSN, MA, RN, continues moving her impactful work to influence the health and well-being of her community. When we both worked at MHCD a number of years ago, I appreciated her initiative in contacting me to offer helpful suggestions for quality improvement from her perspective as a nurse in our outpatient clinics. When I had an opening on my team for a Health Information Systems Manager, I invited her to apply and hired her into this new position where she applied her valuable health care knowledge and skills in a new leadership role. She has continued to grow and contribute her skills in many different roles as a health care leader. As a Nursing Instructor at Platt College, Annette has enjoyed teaching and mentoring nursing students to help them launch successful careers in health care. She has been very active in networking. She contributes to the nursing profession by getting involved in projects, taking on leadership roles, representing nursing and other health care interests in meetings, conducting and publishing research, and presenting at conferences. She enlists others in her network to get involved in community health-promoting activities such as health fairs, and serves on boards of directors of organizations helping to meet the needs of disadvantaged children in the community.38 As Annette has demonstrated throughout her career as a nursing professional and manager, contributing to the profession and your network could get you noticed, and earns support that can increase your impact in creating healthy communities. She continues to be reelected in nursing

124

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

leadership roles and recently won the election in her county for the public office of coroner. Watch for her advocating for important change and continuing to model caring and impactful health care leadership in her new highly visible and important role. Remember Your Passion! Challenges arise at work, even for experienced, well-seasoned managers. Sometimes new approaches and fresh perspective can help if you feel stuck and need a burst of insight to energize you. Revisiting relevant sections in this volume and the first one in this series, Management Skills for Clinicians, Volume I: Making the Transition from Patient Care to Health Care Administration, might help you find and tailor new tools long after your initial transition into management. For me, I found that when I was interviewing people and conducting research for these books, I became aware of many techniques suggested by others that I grew eager to apply for myself in appropriate future opportunities. We conclude with this reminder from Christina Loetscher-Whetsone, RN, who said, “I wouldn’t trade any of it. It’s important to be able to recognize your passion and why you do what you do.”39 Matthew Kelly (2007) tells us that people need the belief that they are moving toward the fulfillment of their dreams, and that work should move people toward those dreams.40 Keep believing in yourself and remember what you value in your work as you move toward being the great health care manager you have dreamed of being!

Chapter Summary and Key Points In this chapter, we saw leaders with long careers who remained energized by building their skills, staying aligned with the mission of their organizations, continually learning new things, and building their interests into their professional work. We looked at the importance of balance and renewal, with a focus on self-care and inclusion of the important elements of life that help you thrive as a person so you can sustain your professional progress and effectiveness. We looked at ways to foster your professional



WHERE DO YOU GO FROM HERE?

125

growth and development. We heard from leaders who had significant impact in the community and showed us how to move from success to significance. Finally, we were reminded of our passion for our work and why we do it. As a health care manager, you have not only learned to arrive, now you also know how to continue to thrive! Key Points: 1. To stay motivated, continue to learn new things and apply your interests to your work. 2. You are your most important resource, so take care of yourself! Take time from sawing to sharpen the axe. Renewal and balance are needed across the dimensions of your life. 3. Mentoring and guiding others can be renewing and enhancing to your own growth. 4. Research by the Gallup organization identified five essential elements that we have some control over and make life worth living. These are labeled as Well-Being in the areas of Career, Social, Financial, Physical, and Community. 5. According to Marcus Buckingham (2005), having a great impact requires that you apply your natural talents and enthusiasm to become good at something, and that you continue to be good at it and more than likely get better. 6. Accepting help from others is important for you to improve. 7. Following up on feedback tells others that you value their perspective. 8. The Stockdale Paradox of Jim Collins (2001) tells us to confront the brutal facts of our situations while having faith that we will prevail. 9. According to Carol Dweck (2006), great leaders have a growth mindset and they are constantly trying to improve. 10. Feedforward asks for ideas from others on something you select for your improvement. It differs from feedback in that it focuses on the future, rather than on criticism of what you did in the past. 11. Experienced managers enhance their success when they move from a focus on personal success to community significance. 12. Remember your passion, purpose, and what you value in your work, and keep believing in yourself!

126

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Learning Activities for This Chapter Here are some questions to help you focus on what works for you to keep your passion ignited and burning bright. 1. Thinking about your current role, what do you find satisfying about it? What do you wish you could change? 2. How does your current role in the organization where you work align with your values? 3. What would you like to try doing that you are not doing now in your current role? How could you make that happen? Could you do it in your current role and organization, would you need to move to another one, or start a new practice or business on your own? 4. What opportunities do you have, or could you create, to mentor and guide others? 5. What examples and recommendations have you seen from leaders, in this chapter or others, that you might want to do to enhance your growth? How would you adapt their approaches to make them work well for you? 6. What challenges have you experienced, or observed in other people who report to you, that signal boredom, unfulfillment, frustration, or being drained? What remedies did you try for yourself, and what would you recommend now for someone else? 7. What are the brutal facts of your current health care environment and how will you build your confidence in knowing you will prevail and succeed? 8. Pick an area where you need to improve. a. How do you know you need to improve in this area? b. What would be the impact of your improving? c. Conduct a feedforward conversation with three people to get their ideas for how you could improve in the future. d. What did you do with their ideas? 9. Where would you like to increase your impact in the community or your profession? a. What activities, groups, committees, work groups, associations, or societies could you join or increase your participation? b. How will your participation be valuable: to the group, to you, and to the organization where you are working now?



WHERE DO YOU GO FROM HERE?

127

10. Conduct this activity, suggested by Jim Donovan (2014),41 to uncover the values of others or yourself. a. Ask an employee, or write down the answer for yourself, “What’s most important to you in your work?” b. Continue to ask the question to build a list. c. Then, move down the list and compare each value to the one listed above it. Ask which one is more important, and move values up or down the list accordingly. d. Now you know the values and order of importance for your employee or yourself. How will you use this information to increase alignment of work activities with values?

APPENDIX A

Grant Funding: Why or Why Not? Sometimes, nonprofit organizations seek support from other sources such as grants from private foundations or government-funded projects, and charitable donations from private individuals or groups. Program and foundation leaders review requests and proposals for funding to consider how their granting of financial support could help deserving organizations extend their services to people in need. Usually there are multiple organizations competing for limited funds, and the funding organizations need to consider how well each applicant organization is likely to utilize the funds responsibly and effectively to get valuable results for the populations served. Often there is a structured Request for Proposals (commonly referred to as RFP) that requires applicant organizations to respond to many questions about how they plan to deliver services, demonstrate their effectiveness, and track and account for their use of the funding. In addition to specific questions about programs and services, they look at many areas of the applicant organizations, including their leadership teams and indicators of financial health. Profit and Loss statements are examined to make sure administrative overhead is not out of proportion to direct service costs. Balance sheets, which look at assets and liabilities, are important in ensuring that applicant organizations have enough net worth (value remaining after covering liabilities) to be able to continue operating into the future.

130

Appendix A

Erica Snow, Portfolio Director at the Colorado Health Foundation, described the due diligence she and her team conduct to select projects to invest in and organizations to fund. Factors they look at include: 1. Senior leadership and their commitment such as participating in site visits from funding organizations: a. Executive teams, with their longevity and turnover b. Board of Director representatives and Board governance 2. Financial statements, indicators of long-term sustainability: a. 3 months cash-on-hand b. Debt-to-equity ratios c. Secured funding moving toward self-sustainability d. Low-interest investments e. Risk propensity—It is good to see some stretching. She noted the challenge in looking at performance metrics for funded projects. These can be difficult to compare objectively because they are not standardized across organizations and populations served. There is a difference between output-oriented metrics, which reflect efforts and process, versus outcomes, which demonstrate results. Often foundations prefer to fund specific projects to help an organization get started in a new line of services, rather than funding general operations. Funders expect the grant recipients to account for their use of funding and the results. This can add a lot of extra work and overhead cost that can make grant-funded projects unprofitable unless such costs are budgeted into your grant proposals and accepted by the funders in their funding award contracts.

Notes Front Matter 1. 2. 3. 4. 5.

Mental Health Center of Denver. (n.d.). Mental Health Partners. (n.d.). Mental Health Partners. (n.d.). Goleman (1995). Ginny Trierweiler, PhD, Licensed Psychologist and Professional Coach, in conversations with the author, 2015 to 2017.

Chapter 1 1. Covey (1989, p. 235). 2. Gene Dankbar, MBA, MS, Senior Principal Health Systems Engineer, Assistant Professor of Health Care Systems Engineering, Mayo Clinic, in an interview with the author, October 24, 2017. 3. Hart (February 26, 2015) 4. Patterson et al. (2012, pp. 170–2). 5. Chris Radigan, LCSW, Program Manager, Mental Health Center of ­Denver, in an interview with the author, February 23, 2015. (Chris was promoted two years later to the position he holds now as Associate Director.) 6. Dauten (May 12, 2011). 7. Jesús Sanchez, PhD, Psychologist at Wardenburg Health Services, in an interview with the author, October 17, 2018. 8. Kelly Phillips-Henry, PsyD, MBA, CEO of Mental Health Partners, in an interview with the author, February 12, 2018. 9. Joanie Gergen, CRCR, in an interview with the author, December 28, 2017, in which she described the fee collection project she led, and the resulting benefits and recognition from its successful implementation. 10. Fielder (1996, p. 20). 11. Blanchard and Johnson (2003, pp. 39–44). 12. Harley (2013, p. 13). 13. Vicki Rodgers, MS, LPC, CHC, CHPC, Chief Operating and Integrity Officer, Mental Health Partners, in an interview with the author, January 31, 2018. 14. Cloud (2013, pp. 205–9).

132 Notes

15. Jeff Zayach, MS, Executive Director of Boulder County Public Health, in an interview with the author, November 30, 2017. 16. LaGanga (2019). 17. Patterson et al. (2012). 18. Jackie Attlesey-Pries, MN, Chief Nursing Officer at Boulder Community Hospital, in an interview with the author, November 10, 2017. 19. Robbins (2013, pp. 176–7). 20. Fred Michel, MD, Chief Medical Officer, Mental Health Partners, in an interview with the author, June 30, 2017. 21. Murphy (2017, p. 191). 22. Stone et al. (1999, pp. 85–93). 23. Cloud (2010, pp. 21–23). 24. Buckingham (2007). 25. Dobson and Dobson (2000). 26. For more on boundaries, see the work of Cloud (2013). 27. Murphy (2017). 28. Stone et al. (1999, pp. 60–67). 29. Harley (2013). 30. For more on establishing your authority in your managerial role, see Volume I, Chapter 2, “So, Now You Are in Charge!” LaGanga (2019).

Chapter 2 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

LaPointe (March 2, 2018). Dunn (March 18, 2015). G&A Partners (n.d.). Altman (January 19, 2017). Kelly (2007, p. 102). The author refers to a study by Bliss and Associates that shows the cost of turnover is at least 150 percent of an employee’s salary. Rosenbaum (January 16, 2018). Waldman et al. (2004, pp. 206–11). Brown (2018, p. 12). Bush (2018, p. 4). Ibid., p. 22. Ibid., p. 24. Ibid., pp. 23–24. C. Clark. Quoted at https://mhcd.org/best-place-to-work (accessed December 29, 2017). Rath and Harter (2010). Carl Clark, MD, CEO of the Mental Health Center of Denver, in an interview with the author, January 16, 2018.

Notes

16. 17. 18. 19. 20.

21. 22. 23. 24. 25. 26. 27. 28.

29. 30. 31. 32.

33. 34. 35. 36. 37. 38.

133

Mental Health Center of Denver (n.d). McGee (April 20, 2018). Leyba (2017). Energage Survey (n.d). The Clifton StrengthsFinder assessment is available online or can be accessed via codes provided in a series of books from the Gallup organization. At the Mental Health Center of Denver, we provided every new employee with a copy of the book, StrengthsFinder (2007), by Tom Rath. Employees were asked to complete the assessment and share the results with their managers, who incorporated the employee’s top five strengths into the coaching and development process. Markle (2000). Buckingham and Coffman (1999). Tucker (February 7, 2014). Starks (Spring 2013). Roy Starks, MA, VP of Rehabilitation Services and Reaching Recovery, Mental Health Center of Denver, in an interview with the author, June 12, 2018. Kelly (2007). Carl Clark, MD, in an interview with the author, January 16, 2018. This model is from the author’s conceptualization of the measurements used by the organization for measuring employee engagement and consumer outcomes, developed for use in presentations she conducted and participated in while working at the Mental Health Center of Denver. It does not necessarily represent the organization’s current materials and models. Carl Clark, MD, in an interview with the author, January 16, 2018. Rath and Conchie (2008). Buckingham and Coffman (1999). LaGanga (2019). Volume I, Chapter 2, “So, Now You Are in Charge!” covers building initial relationships with the people who report to you and some of the other people you work with. Chapter 4, “Managing Up, Down, and All Around,” looks at building relationships with your boss, co-workers, and others. Darcy Jaffe, MN, FACHE, Chief Nursing Officer, Harborview Medical Center, in an interview with the author, September 18, 2017. Messmer, Bogardus, and Isbell (2008, pp. 46–8). Ibid., pp. 54–57. Ibid., pp. 67–68. U.S. Equal Employment Opportunity Commission (n.d.). Americans with Disabilities Act of 1990, as amended with ADA Amendments Act of 2008. https://www.ada.gov/pubs/adastatute08.htm (accessed June 27, 2018).

134 Notes

39. 40. 41. 42. 43. 44. 45.

46. 47.

Rowley and Jackson (2011, pp. 201–2). Sisson and Storey (2000, p. 186). Messmer, Bogardus, and Isbell (2008, p. 104). Ibid., p. 104. Darcy Jaffe, MN, FACHE, Chief Nursing Officer, Harborview Medical Center, in an interview with the author, September 18, 2017. Dixie Casford, MA, LPC, MBA. Vice President of Acute Care Services at Mental Health Partners, in an interview with the author, October 20, 2017. Vicki Rodgers, MS, LPC, CHC, CHPC, Chief Operating and Integrity Officer, Mental Health Partners, in an interview with the author, January 31, 2018. Jeff Tucker, JD, Vice President of Human Resources, Mental Health Center of Denver, in an interview with the author, February 1, 2018. Darcy Jaffe, MN, FACHE, Chief Nursing Officer, Harborview Medical Center, in an interview with the author, September 18, 2017.

Chapter 3 1. Collins (2001, pp. 95–96). 2. This quote is attributed to Sister Generose Gervais, OSF, administrator/ executive director emeritus, Saint Marys Hospital-Mayo Clinic and president, Poverillo Foundation. She said, “I am often quoted, ‘No money, no mission,’ but people fail to recite the entire quote: ‘No mission, no need for money.’ Without mission and appreciation of the long heritage of putting the patient first, we are simply earning money and have no reason to be in health care.” Reported by the Catholic Health Association of the United States in “Sr. Generose Gervais, OSF, Honored with Lifetime Achievement Award.” https://www.chausa.org/newsroom/news-releases/2011/06/06/sr.generose-gervais-osf-honored-with-lifetime-achievement-award, (accessed November 30, 2018). 3. American Hospital Association (February 2018). 4. Community hospitals are defined as all nonfederal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; and other individually described specialty services. Community hospitals include academic medical centers or other teaching hospitals if they are nonfederal short-term hospitals. Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries. 5. Fred Michel, MD, Chief Medical Officer at Mental Health Partners, in an interview with the author, June 30, 2017.

Notes

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

135

Brauer and Kaiser (n.d., p. 18). SocialSecurity.gov (n.d.). Mohr (2003, p. 5). Donai (February 2014, pp. 26–28). Investopedia (2018). Mohr (2003, pp. 19–21). Carl Clark, MD, Chief Executive Officer at Mental Health Center of Denver, in an interview with the author, January 16, 2018. David Dobrzykowski, PhD, MBA, in an interview with the author, April 23, 2018. Lisa Potter, MHA, MBA, Chief Financial Officer, AseraCare, in an interview with the author, June 6, 2018. Sohnen-Moe (2016, pp. 289–91). Julie Artigliere, PhD, Speech-Voice Pathologist and President of Center for Vocal Health, in an interview with the author, October 30, 2017. Dixie Casford, MA, LPC, MBA. Vice President of Acute Care Services at Mental Health Partners, in an interview with the author, October 20, 2017. Joanie Gergen, CRCR, Director of Revenue Cycle at Mental Health Partners, in an interview with the author, December 28, 2017.

Chapter 4 1. Dixie Casford, LPC, MBA, in an interview with the author, October 20, 2017. 2. Dixie Casford, LPC, MBA, in a conversation with the author, November 8, 2018. 3. Barbara Becker, JD, PhD, LPC, in an interview with the author, November 7, 2017. 4. Jim Monk, DDS, in an interview with the author, October 30, 2018. 5. Roy Starks, MA, in an interview with the author, June 12, 2018. 6. Covey (1989, pp. 287–89). 7. Ibid., p. 292. 8. Donovan (2014, p. 14). 9. Ibid., p. 30, 34. 10. Rath and Harter (2010, pp. 5–7, 153–6). 11. Ibid., pp. 5–7. 12. Buckingham (2005, p. 224). 13. Ibid., p. 225. 14. Ibid., p. 279. 15. Ibid., p. 284.

136 Notes

16. Bill Milnor, MA, VP of Business Processes, Mental Health Center of Denver, in an interview with the author, October 12, 2018. 17. Bill Milnor, quoted in Open Minds Executive Briefing, December 2, 2010. “Weeding out the Clinicians in Managers’ Clothing,” https://www .­o penminds.com/market-intelligence/executive-briefings/120210-­ response-staffing-management-clinical (accessed December 7, 2018). 18. Michael Sullivan, MD, in an interview with the author, November 7, 2017. 19. Fred Michel, MD, in an interview with the author, June 30, 2017. 20. George Eliopulos, MD, in an interview with the author, June 30, 2017. 21. David Bachrach, MBA, FACMPE/LFACHE in an interview with the ­author, April 19, 2018. 22. Sohnen-Moe (2016, p. 58). 23. Blanchard and Diaz-Ortiz (2017, p. 89). 24. Jean Rosmarin, PhD, in an interview with the author, October 17, 2018. 25. Dweck (2006, p. 110). 26. Collins (2001, pp. 85–86). 27. Logan and King (2008, p. 83). 28. Kay Martin, LCSW, in an interview with the author, June 1, 2018. 29. Goldsmith (2007, pp. 165–6). 30. Markle (October 21, 2018, p. 6K). 31. Goldsmith (2007, pp. 170–5). 32. Ibid., pp. 166–9. 33. Gene Dankbar, MS, MBA, in an interview with the author, October 24, 2017. 34. Elvira Ramos, in an interview with the author, October 24, 2017. 35. Carl Clark, MD, in an interview with the author, January 16, 2018. 36. Vaccarelli (November 15, 2016). 37. Meadows (n.d.). 38. Annette Cannon, PhD, MSN, RN, Nursing Instructor at Platt College, in an interview with the author, October 19, 2017. 39. Christina Loetscher-Whetstone, RN, in an interview with the author, March 26, 2015. 40. Kelly (2007). 41. Donovan (2014, pp. 30–32).

References Altman, J. January 19, 2017. “How Much Does Employee Turnover Really Cost?” HuffPost, https://m.huffpost.com/us/entry/ us_587fbaf9e4b0474ad4874fb7/amp, (accessed June 26, 2018). American Hospital Association. February 2018. “Fast Facts on US ­Hospitals.” https://www.aha.org/system/files/2018-02/2018-aha-hospital-fast-facts .pdf Blanchard, K.H., and S. Johnson. [1981,1982] 2003. The One Minute Manager. New York, NY: HarperCollins. Blanchard, K.H., and C. Diaz-Ortiz. 2017. One Minute Mentoring. New York, NY: HarperCollins Publishers. Brauer, L.M., and C.F. Kaiser. n.d. “Tax-Exempt Health Care Organizations Community Board and Conflicts of Interest Policy,” p. 18. https://www.irs.gov/pub/irs-tege/eotopicc97.pdf, (accessed June 16, 2018). Brown, B. 2018. Dare to Lead: Brave Work, Tough Conversations, Whole Hearts. New York, NY: Random House. Buckingham, M. 2007. Go Put Your Strengths to Work: 6 Powerful Steps to Achieve Outstanding Performance. New York, NY: Free Press. Buckingham, M. 2005. The One Thing You Need to Know. New York, NY: Free Press. Buckingham, M., and C. Coffman. 1999. First, Break All the Rules: What the World’s Greatest Managers Do Differently. New York, NY: Simon & Schuster. Bush, M.C., and The Great Place to Work Research Team. 2018. A Great Place to Work for All. Oakland, CA: Berrett-Koehler Publishers, Inc. Cloud, H. 2013. Boundaries for Leaders: Results, Relationships, and Being Ridiculously in Charge. New York, NY: HarperBusiness. Cloud, H. 2010. Necessary Endings. New York, NY: Harper-Collins Publishers.

138 References

Collins, J.C. 2001. Good to Great: Why Some Companies Make the Leap. . .and Others Don’t. New York, NY: HarperCollins. Covey, S.R. 1989. The 7 Habits of Highly Effective People. New York, NY: Simon and Schuster. Dauten, D. May 12, 2011. “‘Are You Above Office Politics?’ in the ­Career Advice Column, ‘JT and Dale Talk Jobs.’” http://www.jtanddale .com/?p=1242#more-1242, (accessed February 1, 2018). Dobson, M.S., and D.S. Dobson. 2000. Managing Up: 59 Ways to Build a Career-Advancing Relationship with Your Boss. New York, NY: ­American Management Association. Donai, J.J. Februaray 2014. “Practice Management: Look to Financial Statements before You Leap.” The Hearing Journal 62, no. 2, pp. 26–28. Donovan, J. 2014. Happy @ Work. Novato, CA: New World Library. Dunn, L. March 18, 2015. “Getting a Handle on Hospital Workforce Costs,” Hospitals & Health Networks, https://www.hhnmag.com/ articles/3614-getting-a-handle-on-hospital-workforce-costs, (accessed June 25, 2018). Dweck, C. 2006. Mindset. New York, NY: Ballantine Books. Energage Survey. n.d. “Energage Employee Engagement Survey,” https:// www.energage.com/survey, (accessed November 29, 2017) Fielder, B. 1996. Motivation for the Workplace. Mission, KS: Skillpath Publications. G&A Partners. n.d. “Calculating the High Cost of Employee Turnover.” https://www.gnapartners.com/article/how-much-does-employeeturnover-really-cost-your-business, (accessed June 26, 2018). Goldsmith, M. 2007. What Got You Here Won’t Get You There. New York, NY: Hyperion. Goleman, D. 1995. Emotional Intelligence: Why It Can Matter More than IQ. New York, NY: Bantam Books. Harley, S. 2013. How to Say Anything to Anyone. Austin, TX: Greenleaf Book Group Press. Hart, H. February 26, 2015. “Yes, and . . . 5 More Lessons in Improving ­Collaboration and Creativity from Second City,” FastCompany. https:// www.fastcompany.com/3042080/yes-and-5-more-lessons-in-improving-collaboration-and-creativity-from-second-city, (accessed January 8, 2018).

References

139

Investopedia. 2018. “Cash Flow.” https://www.investopedia.com/ terms/c/cashflow.asp, (accessed October 19, 2018). Kelly, M. 2007. The Dream Manager. New York, NY: Hyperion. LaGanga, L. 2019. Management Skills for Clinicians, Volume I: Making the Transition from Patient Care to Management and Administration. New York, NY: Business Expert Press. LaPointe, J. March 2, 2018. “Hospitals Target Labor Costs, Layoffs to Reduce Healthcare Costs,” RevCycle Intelligence. https://revcycleintelligence.com/news/amp/hospitals-target-labor-costs-layoffs-toreduce-healthcare-costs, (accessed June 25, 2018). Leyba, J. 2017. “Denver Post’s Seventh-annual Top Workplaces Contest Begins,” The Denver Post. https://www.denverpost.com/2017/09/10/ denver-post-top-workplaces-contest-2018, (accessed December 29, 2017). Logan, D., and J. King. 2008. Tribal Leadership. New York, NY: Harper Business. Markle, G.L. 2000. Catalytic Coaching: The End of the Performance Review. Westport, CT: Quorum Books. Markle, G. October 21, 2018. “Coachability Sets Stage for Performance Improvement.” The Denver Post, p. 6K. McGee, T. April 20, 2018. “Top Workplaces: Building a Diverse and Inclusive Workplace is More than Just a Cliche for these Companies,” The Denver Post. https://www.denverpost.com/2018/04/20/2018-topworkplaces-diverse-inclusive-workplace, (accessed April 23, 2018). Meadows, J. 2018. “Sanderson Apartments is One of Nation’s First Buildings Designed under Principles of Trauma-informed Care.” https:// www.enterprisecommunity.org/news-and-events/news-releases/­ sanderson-apartments-employs-trauma-informed-design,  (accessed July 14, 2018). Mental Health Center of Denver. n.d. https://mhcd.org/get-to-know-us, (accessed November 20, 2018). Mental Health Center of Denver. n.d. “The Mental Health Center of Denver has been named a Top Work Place by the Denver Post Five Years in a Row!” https://mhcd.org/best-place-to-work, (accessed ­December 29, 2017). Mental Health Partners. https://www.mhpcolorado.org/about, (accessed November 20, 2018)

140 References

Messmer, H., A. Bogardus, and C. Isbell. 2008. Human Resource Management. Hoboken, NJ: John Wiley & Sons, Inc. Mohr, A. 2003. Financial Management 101: Get a Grip on Your Business Numbers. Bellingham, WA: Self-Counsel Press. Murphy, M. 2017. Truth at Work. New York, NY: McGraw Hill Education. Patterson, K., J. Grenny, R. McMillan, and A. Switzler. 2012. ­Crucial Conversations: Tools for Talking When Stakes Are High. 2nd ed. New York, NY: McGraw-Hill. Rath, T. 2007. StrengthsFinder 2.0. New York, NY: Gallup Press. Rath, T., and B. Conchie. 2008. Strengths Based Leadership: Great Leaders, Teams, and Why People Follow. New York, NY: Gallup Press. Rath, T., and J. Harter. 2010. Wellbeing: The Five Essential Elements. New York, NY: Gallup Press. Robbins, S.P. 2013. The Truth about Managing People. 3rd ed. Upper Saddle River, NJ: FT Press. Rosenbaum, M. January 16, 2018. “Will 2018 be the Year Healthcare Addresses its Turnover Problem?” Becker’s Hospital CFO Report, https:// www.beckershospitalreview.com/finance/will-2018-be-the-yearhealthcare-addresses-its-turnover-problem.html, (accessed June 26, 2016). Rowley, C., and K. Jackson (eds.). 2011. Human Resource Management. New York, NY: Routledge. Sisson, K., and J. Storey. 2000. The Realities of Human Resource Management. Philadelphia, PA: Open University Press. SocialSecurity.gov. n.d. “What is FICA?” https://www.ssa.gov/thirdparty/ materials/pdfs/educators/What-is-FICA-Infographic-EN-05-10297 .pdf, (accessed December 2, 2018). Sohnen-Moe, C.M. 2016. Business Mastery: A Guide for Creating a Fulfilling, Thriving Practice and Keeping it Successful. Tucson, AZ: Sohnen-Moe Associates, Inc. Starks, R. Spring 2013. “Building a Wellness Culture for Staff to Promote a Recovery Culture for Consumers.” Mental Health News, p. 22. Stone, D., B. Patton, and S. Heen. 1999. Difficult Conversations: How to Discuss What Matters Most. New York, NY: Penguin Books. The Denver Post. December 9, 2017. “Denver Post’s seventh-annual Top Workplaces contest begins,” https://www.denverpost.com/2017/09/10/ denver-post-top-workplaces-contest-2018, (accessed December 29, 2017).

References

141

Tucker, J. February 7, 2014. “Getting Engaged: How to Boost Employee Satisfaction,” ColoradoBiz. http://www.cobizmag.com/articles/gettingengaged, (accessed November 17, 2017). U.S. Equal Employment Opportunity Commission. n.d. “About the EEOC: Overview.” https://www.eeoc.gov/eeoc (accessed June 27, 2018). Vaccarelli, J. November 15, 2017. “Mental Health Center’s Dahlia Campus Wins Mayor’s Award,” The Denver Post. https://www.denverpost .com/2016/11/15/mental-health-center-dahlia-campus-award Waldman, J.D., F. Kelly, S. Arora, and H.L. Smith. 2004. “The Shocking Cost of Turnover in Health Care.” Health Care Management Review 35, pp. 206–11.

About the Author Linda R. LaGanga has 30 years of management experience. She ­provided clinical care directly to her clients in a community mental health center. She applied her management and process improvement skills she had gained from her prior career in a startup computer software company, where she built the customer support organization and rose to senior management. She served in executive levels of management in healthcare organizations. She has published, taught classes, and conducted workshops in process improvement, clinical appointment scheduling, quality management, hiring and human resources, and Mental Health First Aid. Linda helps people and organizations to discover their strengths and apply their resources to serve their customers and patients effectively. She serves as an advisor to several healthcare technology startup companies. Linda earned her bachelor of science in applied mathematics and computer science from the University of Rhode Island and a master of science degree in operations research and statistics from Rensselaer ­Polytechnic Institute. Her yearning to help people improve their lives led her to complete a master of arts in clinical mental health counseling at Rivier College. Soon after joining a community mental health center as a therapist, she applied her passion and experience to improve large healthcare systems. To advance her skills in analytical methodologies, she earned a PhD in operations research from the University of Colorado. Linda’s award-winning research and projects have been published in scholarly journals and presented at international conferences, including several Mayo Clinic Conferences on Systems Engineering and Operations Research in Health Care.

Index ABC’s, dialogue of, 3–4 Administrative allocation, 80–81 Assessment approaches, 39 Balance sheet, 91–94 Barriers, communication, 8–10 Behavioral interview questions, 51–53 Boredom, 109–110, 113–115 Budgeting, 69–70 administrative allocation, 80–81 concepts, 84 cycles, 71–72 example, 72–75 fiscal year periods, 71–72 formats, 83–84 grant funding, 78–79 managing, 70 way of spending, 70–71 Business goals, 97–98 Cash flows, 98 Cash flow statement, 85–88 Chart of accounts (COA), 77 Clinical practice, financial principles of, 97–100 business goals, 97–98 cash flow and, 98 healthy finance and, 99 mastery of business principles, 98–99 Coachability, 119–120 Communication, guidelines for, 2–10 ABC’s of dialogue, 3–4 barriers, 8–10 healthy, 6 omissions, 5–6 open dialogue, building of, 2 silos, 8–10 WENK model, 7 written communication, 4–5 Compensation, 59–60

Conflict, relationships and, 13–22 blame vs. contribution, 19–20 conversation and, 16–17 cues, adoption of, 15–16 discomfort, 17–18 embracement of, 14–15 handling in, 18–19, 22 initiation of, 19 perspectives of others, 20 reason for, 13–14 role-related powers, 20–21 Corrective feedback, 11–12 Culture, organization and, 33 Diversity, organization and, 34–35 Employee engagement, organization and, 32 Employee strengths, organization and, 31–32 Feedback, 10–13 corrective, 11–12 improvement and, 118–119 interviews and, 58–59 positive, 10–11 receiving of, 12 “Start, Stop, and Continue” approach, 12–13 Feedforward, improvement and, 121 Financial management, 94–97. See also Budgeting; Money; Profit contributions and alignment, 95–96 drivers, understanding of, 95 review reports and data, 94–95 spending, tracking and managing of, 96 variations, recognizing, 97

146 Index

Financial principles, clinical practice and, 97–100 business goals, 97–98 cash flow and, 98 healthy finance and, 99 mastery of business principles, 98–99 Fiscal year periods, 71–72

Job advertisement, 48 Job description, review of, 47–48 Job offers, 59–60

Grant funding, 78–79, 129–130 Growth and improvement, 117–121 coachability, 119–120 feedback and, 118–119 feedforward and, 121

Mastery of business principles, 98–99 Meetings, 120, 122 Mentoring, 115–116 Money economics, clinical practice and, 67–68 importance of, 66 management of, 67

Healthy finance, 99 Hiring, 42–45. See also Selection process advertisement, 48 contact with HR, 46–47 developing positive working relationships, 45 dissemination, 48 form for roadmap to, 63 job description, review of, 47–48 positions open up, 46 posting, 48 refilling, evaluate and plan for, 47 rehiring needs, communicate and evaluate, 46 Human resources (HR), 42–45. See also Hiring Inclusiveness, organization and, 34–35 Income statement, 88–90 Interviews, 51–59 basic requirements, confirmation of matches with, 51 behavioral interview questions, 51–53 feedback from HR, 58–59 open-ended questions, 53–54 reference and background checks, 57–58 right candidates, selection of, 56 skills demonstrations, 55–56 styles and approaches, exploring, 54–55

Leadership, 104–106 business management skill, 104, 118 meetings, role of, 120, 122

Net profit, 69 Nonprofit organizations, 66–67 Omissions, communication, 5–6 Onboarding, 60 Open dialogue, building of, 2 Open-ended questions, interviews and, 53–54 People, importance of, 28–30 costs and consequences of turnover, 28–29 lower turnover in positive workplace cultures, 29–30 Place to work, organization and, 30–39 pillars of, 35–36 unified themes, 36–39 Positive feedback, 10–11 Profit, 68–69 Purpose, description of, 107 Recognition, organization and, 30–31 Relationships, conflict in, 13–22 blame vs. contribution, 19–20 conversation and, 16–17 cues, adoption of, 15–16 discomfort, 17–18 embracement of, 14–15 handling in, 18–19, 22

Index

initiation of, 19 perspectives of others, 20 reason for, 13–14 role-related powers, 20–21 Selection process, organization of, 48–51 fairness and employment laws, 48–49 interview questions, 50–51 interview team, 50–51 reviewing applications, 50 screening, 50 Self-care, importance of, 106–107 Silos, communication and, 8–10 “Start, Stop, and Continue” approach, 12–13 Strengths-based employee development, 41 Strengths-based leadership, 39–40 Strengths-based teams, 42 Sustained success, 109–116

Team strengths, 39–42 assessment approaches, 39 by domain, 40 strengths-based employee development, 41 strengths-based leadership, 39–40 strengths-based teams, 42 Training, organization and, 31 Vacancies, 46 Values, description of, 107 Well-being, five elements of, 108 WENK model, 7 Work balancing life and, 108 purpose and, 107 success tips, 109–116 Written communication, 4–5

147

OTHER TITLES IN OUR HEALTHCARE MANAGEMENT COLLECTION David Dilts, Oregon Health & Science University (OHSU) and Lawrence Fredendall, Clemson University, Editors • Quality Management in a Lean Health Care Environment by Daniel Collins and Melissa Mannon • Improving Healthcare Management at the Top: How Balanced Boardrooms Can Lead to Organizational Success by Milan Frankl and Sharon Roberts • The Patient Paradigm Shifts: Profiling the New Healthcare Consumer by Judy L. Chan • Leading Adaptive Teams in Healthcare Organizations by Kurt C. O’Brien and Christopher E. Johnson

Announcing the Business Expert Press Digital Library Concise e-books business students need for classroom and research This book can also be purchased in an e-book collection by your library as • • • • •

a one-time purchase, that is owned forever, allows for simultaneous readers, has no restrictions on printing, and can be downloaded as PDFs from within the library community.

Our digital library collections are a great solution to beat the rising cost of textbooks. E-books can be loaded into their course management systems or onto students’ e-book readers. The Business Expert Press digital libraries are very affordable, with no obligation to buy in future years. For more information, please visit www.businessexpertpress.com/librarians. To set up a trial in the United States, please email [email protected].

Management Skills for Clinicians, Volume II

EBOOKS FOR BUSINESS STUDENTS

Linda R. LaGanga

POLICIES BUILT BY LIBRARIANS • Unlimited simultaneous usage • Unrestricted downloading and printing • Perpetual access for a one-time fee • No platform or maintenance fees • Free MARC records • No license to execute The Digital Libraries are a comprehensive, cost-effective way to deliver practical treatments of important business issues to every student and faculty member.

For further information, a

This book will be helpful in supporting those wanting to promote in the field. —Louise Delgado, LPC, CEO of Solvista Health I like the book using the numerous other authorities from which Linda has drawn . . . this book will become the ‘go-to’ source because with it you can find tons of resources if special attention is needed in one area. —Curtis Smith, Attorney, former board member of MHCD In this second volume for clinicians who have transitioned into administration, we continue the journey to advance management skills. Developing business skills in hiring, human resource management, and financial management will help garner and administer the resources that support a team’s important work. Readers will learn to embrace conflict and handle it constructively, as well as deepen skills for developing personal and team member strengths to enhance performance and sustain success as a health care manager. Linda R. LaGanga has 30 years of management experience. With a master’s degree in clinical mental health counseling, she worked directly with clients in community mental health. She applied her management and process improvement skills she had gained from her prior career in a startup computer software company, where she built the customer support organization and rose to senior management. She advanced to executive levels of management in healthcare organizations. Her PhD in operations research contributed new approaches to expanding access to healthcare services. She has published, taught classes, and conducted workshops in process improvement, clinical appointment scheduling, quality management, hiring and human resources, and mental health first aid. Linda helps organizations and people to discover their strengths and apply their resources to serve their customers and patients effectively.

free trial, or to order, contact:  [email protected] www.businessexpertpress.com/librarians

Healthcare Management Collection David Dilts and Lawrence Fredendall, Editors

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME II

Curriculum-oriented, borndigital books for advanced business students, written by academic thought leaders who translate realworld business experience into course readings and reference materials for students expecting to tackle management and leadership challenges during their professional careers.

Advancing Your Skills

LAGANGA

THE BUSINESS EXPERT PRESS DIGITAL LIBRARIES

Healthcare Management Collection David Dilts and Lawrence Fredendall Editors

Management Skills for Clinicians, Volume II

Advancing Your Skills

Linda R. LaGanga