Management Skills for Clinicians, Volume I: Transitioning to Administration 1606498169, 9781606498163

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Management Skills for Clinicians, Volume I

EBOOKS FOR BUSINESS STUDENTS

Linda R. LaGanga

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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 This book introduces new healthcare managers to the skills they need to transition and succeed in their managerial roles. More experienced managers can benefit, too, from examples and collected insights of other managers who were interviewed and from examples in recent and revisited literature. The author covers both “hard” business skills and “soft” people/organizational skills. We draw from books, articles, examples, and managerial experience of the author and colleagues at different organizational levels and throughout healthcare settings and professions. 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.

Healthcare Management Collection David Dilts and Lawrence Fredendall, Editors

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME I

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.

Transitioning to Administration

LAGANGA

THE BUSINESS EXPERT PRESS DIGITAL LIBRARIES

Healthcare Management Collection David Dilts and Lawrence Fredendall Editors

Management Skills for Clinicians, Volume I Transitioning to Administration

Linda R. LaGanga

Management Skills for Clinicians, Volume I

Management Skills for Clinicians, Volume I Transitioning to Administration Linda R. LaGanga

Editors David Dilts Larry Fredendall

Management Skills for Clinicians, Volume I: Transitioning to Administration 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: 978-1-60649-816-3 (paperback) ISBN-13: 978-1-60649-817-0 (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 This book introduces new managers working in health care to the basic skills and competencies to support them in transitioning to their managerial roles. Some topics and examples also can help more experienced managers reassess and revitalize their skills. Targeted readers have been promoted recently into managerial, supervisory positions. They have 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. The book covers both “hard” business skills and “soft” people/organizational skills. We draw from books, articles, examples and managerial experience of the author and colleagues at different organizational levels and throughout health care settings and professions.

Keywords management; supervisory; leadership; meetings; time management; ­employee performance; employee coaching; healthcare administration

Contents Preface...................................................................................................ix Acknowledgments.................................................................................. xxi Chapter 1 Introduction to Health Care Management.........................1 Chapter 2 So, Now You Are in Charge! Leading Your Team and Managing When Others Report to You.....................19 Chapter 3 Planning and Organizing.................................................65 Chapter 4 Managing Up, Down, and All Around!..........................107 Appendix A Interview Participants and Selected Highlights...............133 Appendix B Meeting Agenda Form...................................................145 Appendix C Example of an SBAR......................................................147 Notes..................................................................................................151 References............................................................................................163 About the Author.................................................................................167 Index..................................................................................................169

Preface Overview of Your Management Journey Welcome to the world of health care management! Working in health care, you have chosen a meaningful career that helps people live better, healthier lives. You have developed extremely valuable clinical knowledge and skills through your education and training, followed by your experience working directly with patients and in organizations that provide health care. By stepping up into managerial and other leadership roles, you are taking responsibility for greater impact and well-being through the contributions of your team members and other colleagues you lead, both within your organization and beyond in the communities you influence. There are many new skills for you to learn that help you leverage your valuable experience to maximize your effectiveness as a health care manager and administrator. To 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 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

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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 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

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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. Help is our promise. Health is our passion.—Mental Health Partners (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 Mental Health Partners was one of four community mental health centers accepted into the Colorado State Innovation Model (SIM), a federally

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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 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 “nutsand-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.

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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 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 enhances 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.

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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. 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’s 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

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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 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

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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 • 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. For further information on these and other topics related to work culture, employee strengths, and hiring, please see Chapter 2 in Volume II. 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.

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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. 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 your successful transition to administration

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• 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 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

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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 • 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’s important, even in nonprofit organizations

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• • • • • • •

Budgeting for what you’re managing Your budget: what it looks 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

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

Introduction to Health Care Management Chapter Overview 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 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 for 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

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Motivation for Developing Management Skills Interviews with many health care leaders provided real-world examples and recommendations that confirmed the importance of the topics in this book. These address skills that may be particularly challenging to new managers in health care because they were not part of their professional education and may be considered at odds with traditional values associated with caring for patients. In this chapter, we introduce some of the themes and lessons gleaned from interviews, identify some particular challenges in refocusing your clinical training to succeed as a health care manager, and offer some activities to help you focus as you get started. For example, holding staff accountable for performance metrics may feel uncomfortable and in conflict with clinical training that taught us to be nonjudgmental and emphasized support, comfort, and understanding toward patients when they were going through difficult times. Getting teams focused and moving forward on higher-level organizational goals requires teamwork and collaboration that might have been absent from highly competitive and demanding clinical programs that required mastery of complex scientific material. On the other hand, our clinical training and experience provide valuable assets for us to build on in our journey toward being successful in management. What we learned and practiced in goal-setting with patients can teach us about setting realistic and relevant goals, which is helpful in managing teams and projects.

What’s So Special about Health Care Management? Health care is a complex business. It is not just the patients and clients, being the direct recipients of our care and treatment services, who are considered our customers. In addition, the organizations we work for are accountable to the payers of those services, typically insurance plans, grant funding administrators, and other government entities, who also require data and reports to monitor organizational performance. Perspectives from a variety of clinicians, managers, and administrators help us understand and manage successfully in the challenging and rewarding arena of health care.



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Deep Caring about the People and the Work People who work in health care really care about the people they help and the work they do. Everyone I interviewed cares deeply about the people and communities they serve and the teams of people they lead. Paul Bretz, LCSW, DDiv, Executive Director of Centus Counseling, has a wide collection of educational degrees, has earned professional certifications in clinical practice, quality, and compliance, and has in-depth experience in clinical, spiritual, administrative, and leadership roles. He expressed this commitment vividly when he said, “In a meeting, every person who talked about a client teared up. It doesn’t get much better than that!”1 When I asked Preston Simmons, MHA, DSc, FACHE, “What is special about working in health care?” from his perspective as the administrator of one of the largest health care organizations in the United States, he explained that people working in health care want to make a difference; clinicians have a passion for patient care and pay attention to good outcomes. High integrity is particularly important.2 Rapid Change for Efficiency Ken Bellian, MD, MBA, has a range of valuable experiences as a physician, chief medical officer, university instructor on health care innovation, entrepreneur, and advisor for organizations developing technological solutions to difficult health care problems. He describes the world of health care as changing rapidly with continuing need for efficiency to drive down costs as expectations rise for patients’ needs to be met quickly with good outcomes. This requires focus, persistence, and insistence, enveloped in the driving context of meeting patient needs. He believes an effective health care leader must communicate to the staff the process and strategy for meeting these needs. He described change as unsettling to most people; as a leader, your ability to make your staff feel valued, heard, understood, and respected is essential to manage the change successfully. Managers can help people move forward by identifying the early adopters who figure out how to improve their patient flow to see more patients while completing their administrative requirements promptly, and supporting others in adopting

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effective practices, utilizing helpful technology, to improve their working lives and the experience of their patients.3 Complicated Drivers of Delivery Indeed, the complicated operational levers that drive health care delivery can be very difficult to understand. Vonderembse and Dobrzykowski (2016) explain managerial challenges that are specific to health care. For example, supply and demand for health care services can be difficult to balance because of insurance payment systems that insulate patients from true costs of care and may lead to overutilization of services. Rapidly shifting reimbursement models can be difficult to comprehend and implement, especially when technological infrastructure for information sharing is still evolving. And, the total cost of health care is driven not only by the number of units of care delivered, but also by the price of each claim or unit of care, thereby causing increasing pressure to enhance efficiency, reduce waste, and improve collaboration and resource management.4 Ensuring Standards Are Met In health care settings, you may find that as you rise to higher levels of management, you spend more time dealing with people and organizations outside of your own. Patients, clients, and their family members may seek a manager, someone in charge—you! —when they are dissatisfied with the care and treatment they received from a clinician. You are also likely to deal with external administrative functions involved in the payment for health care services, assurance of compliance with health and safety rules and regulations, and patient privacy laws. You will be responsible for ensuring that the work of your team or department conforms to standards of clinical care, documentation, and billing, along with internal performance targets that are needed to keep the organization running well.

Interviews for a Variety of Perspectives More than 60 accomplished health care professionals across a wide range of health care professions and settings graciously participated in interviews and



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conversations with me to share their insights and recommendations about becoming an effective health care manager. All of them are listed in Appendix A along with some selected highlights of interview themes. You will meet some of these people in this chapter, and you will see others later in chapters where their advice and examples are particularly relevant. They bring valuable experience from many roles and levels, including clinicians, early-career initial supervisors and managers, through directors, vice presidents, executive directors, chief executive officers, and governing boards of directors. You will see experiences and insights from physicians, nurses, psychologists, social workers, psychotherapists, and other providers and administrators. Their experience comes from a variety of settings from outpatient, hospital, academic medical centers, and universities, with health care focus in physical and behavioral health, home health care, physical and voice therapy, dental practice, pharmacy operations and other specialty areas. They represent different sectors such as not-for-profit, for-profit, and governmental. I selected effective managers and leaders to interview to explore specific aspects of their experience as new and developing managers. As I have worked with many of them, I have admired their effectiveness and know the value they have contributed to their organizations and professions. I wanted to find out and share with you more about their backgrounds, perspectives, and the history and application of tools and approaches they contributed to our work practices and cultures. Other participants were recommended by people I had selected to interview, who envisioned particular value that could be added by some of their trusted colleagues. And I sought out additional participants through my network of contacts and their contacts to broaden the field of multiple clinical perspectives and deepen the perspective constructed from multiple contributors. I chose them specifically to broaden the base of experience and perspectives from a wider variety of health care professions and settings. And in the course of my ongoing activities, I encountered others whom I already knew or was just meeting; when I told them about this book and its purpose, they strongly agreed with the need and offered insights and examples from their experiences that can help address important issues that new health care managers face.

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Many shared experiences and recommendations are collected and summarized throughout this book. To bring to life key points and illustrate how you can apply them in practical situations, some composite scenarios are drawn from interviews, conversations, and my prior experience and observations. Some details are combined and altered to highlight important principles while preserving confidentiality and privacy of interview participants and others who were involved in sensitive situations.

Interview Questions I started with a structured form to elicit specific information from those I interviewed about their backgrounds and experience as new and evolving health care managers, along with their recommendations and advice for others starting out as new health care managers. I asked: 1. When and where (in what organization) did you have your first experience as a manager? 2. What were you doing before this transition to manager? 3. Why did you want to be a manager? 4. Why do you think you were selected to become a manager? 5. How much were your initial expectations met about your new role? 6. What pleasant surprises and unexpected challenges did you find? 7. What do you think contributes to the success of a new manager? 8. What worked well for you in getting started in your new role? 9. What would you have done differently? 10. What helped you get started in your new position as a manager? 11. Was there particular training, support, mentoring, materials, or other resources that you found helpful? 12. What else would have been helpful to you in getting started as a new manager? 13. How did you fill the gaps or get these other things? 14. What advice do you have for other clinicians moving into manager roles? 15. What other things would you like to share about your experience? Ad-hoc questions were used as needed to clarify and explore interesting things that came up.



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The interviews were designed to start by eliciting some specific information about how people got started as new managers, what did and did not work for them, for the purpose of guiding other new managers. Later questions broadened to allow participants to expand on relevant parts of their experience and to contribute interesting insights and recommendations. Several of the later conversations and interviews were less structured to allow deeper exploration of some specific perspectives and insights that were particularly relevant to those participants’ experiences or disciplines.

Themes from Interviews A number of experiences and suggestions emerged as commonly mentioned themes throughout the interviews. This chapter includes a small sample of the comments from some of the interviewees. For more examples, please see Appendix A. You’ll meet more of the interviewees and hear from them as you progress through later chapters. Expectations A number of meaningful themes emerged in discussions with these managers and leaders across roles and settings. Many emphasized the importance of understanding performance expectations; managers should know clearly what is expected of them from the manager and leaders above themselves and must be clear in communicating expectations to the people they supervise. Stepping Up to Earn Credentials and Responsibility Most of the clinically trained people mentioned the value and importance of earning credentials, experience, and in many cases licensure that established their credibility and responsibility. This willingness and ability to step forward helped prepare these clinicians for greater responsibility and facilitated their selection for promotion and expanded roles that became available within their current workplaces or to transition to higher levels of responsibility and leadership in new settings. Several nurses talked about the value and importance of being credentialed as registered nurses and how it helped establish their leadership

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with hospital teams. As charge nurses, they began to assume responsibility for coordinating activities on their shifts and making sure the patients in their charge received high-quality care. Part of this responsibility included advocating for their patients and other staff, which required being in tune with the needs of others and being willing to negotiate with higher-level administrators to meet those needs.5,6,7 Managers working in behavioral health care, in outpatient clinics, or in residential treatment settings, began as therapists, case managers, or counselors, and earned their licensure as licensed clinical social workers, licensed professional counselors, or licensed addictions counselors while working directly with patients (whom they also refer to as clients and consumers). Yet, not every licensed or certified clinician makes the move into a manager position, and so what differentiated these people? What emerged was not only a willingness to accept responsibility when it was offered but the initiative to seek greater challenges, to risk trying new things, and to embrace uncertainty and change.8,9,10 Seek and Be Sought for Leadership The MDs who spoke with me exemplify impressive careers of increasing responsibility and leadership.11,12 As Kenneth T. Bellian, MD, MBA, observed, medical education is devoid of management training and does not prepare you for the increasing responsibilities of management. Some of the common ways to gain more management responsibilities are to either actively seek out leadership positions or to be identified as a potential leader. Commonly, providers are recognized as great clinicians, excellent teachers, or successful researchers. They are subsequently promoted as future leaders into management. Without formal management training in the medical educational system, it is incumbent upon the individual and the organization to actively support the provider’s leadership development.13 For most of the MDs, in their initial transition to managerial responsibilities, they stepped up to fill the need for leadership. Kristi Mock, LCSW, Chief Operating Officer of the Mental Health Center of Denver, started 34 years ago as a therapist. Her continual progression to higher levels and broader scopes of responsibility began with volunteering to cover interim management responsibilities when



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there was a gap. “Be that person leadership can count on,” she advises, and “volunteer to do lots of different things to expand viewpoints and perspectives, while continuing to be a high performer in your primary responsibilities.”14 Constructive Engagement Several said that although they did not see the transition to administration coming, they embraced it. Donald Penning, MD, of Denver Health, sought education and training in management, and continues to proactively handle culture change. It means getting truly involved with the work and people, continuing to build clinical competence, and not focusing on job titles. When Dr. Penning was at Denver Health as director of anesthesia, he broadened his reach by assuming responsibility for all operating room functions, while conducting research and applying operations research methodology to increase efficiency. He later moved to Henry Ford Health System as vice chair of research, head of neuroanesthesia, and professor of anesthesiology and neurosurgery. When Dr. Penning invited me to visit and observe him and his ­Denver Health team in action, I found it inspiring to see him actively leading his staff in a daily check-in. His team members were busily engaged in working collaboratively on their team when they were recognized by their leaders and their peers for the successful events of the previous day, followed by constructive conversation with the team on what could be improved. Dr. Penning attributes his success to a collaborative attitude and willingness to “not just have the job but do the job,” which he learned in a management course he completed.15 Helping People Get the Work Done A leader who has led in many different settings is licensed clinical psychologist Jesús Sanchez, PhD, who has worked in medical rehabilitation, community mental health, a state psychiatric hospital, private practice, student health center, group consulting practice, and as a member of governing boards of directors. He has mastered a range of skills as a manager and administrator. Like others I spoke with, his strong performance as

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a clinician and his abilities to organize and take responsibility for strategically important preparation for managed care implementation were noticed by top management, and soon he was promoted into a program manager role. “I didn’t know anything about management, but I knew my job was to help my team do their job. Managers need to facilitate the team doing its work more efficiently,” he explained, and added that facilitating is not just telling people to do things; it involves building relationships with other teams and organizations that foster productive collaboration that helps people get the work done.16 Applying Varying Experiences and Perspectives Many people demonstrated talents such as seeing opportunities to make things work better,17 understanding potential challenges and strategizing how to navigate successfully in their work settings, along with focusing on the important details that are needed to implement projects while growing and empowering their staff members to develop their abilities as clinicians and leaders. Many interviewees applied transferable skills they developed in earlier settings, including general business settings18 and military service19 to help their new organizations operate more effectively. “Military service was one of the most valuable experiences of my life,” said Bill M ­ ilnor, MA, VP of Business Processes at the Mental Health Center of Denver. There he learned discipline and to work as a team toward the mission.20 Apply Your Strength and the Strengths of Others Many people had assessed their strengths and those of their teams. Many used formal assessment tools, and others learned to recognize what they and their team members naturally gravitated toward doing. Mary Ellen Benson, VP of Healthcare Transformation and Development at Aspen Pointe, started as a physical therapist and advanced to leadership roles and high levels of executive management through her abilities to work well with people and get things done effectively. She shared good advice she received from a CEO she reported to, “Be who you are and lead from within.”21 Relationships Foster Learning and Growth These leaders all demonstrate deep self-awareness with openness to learn and explore new approaches and share them with others. Clinical and



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medical training taught them to focus on patients and listen to others. They recognize the importance of building relationships within and outside their organizations to foster their growth and help get things done. Most of our interviewees started in their new manager roles with no prior training in how to be a manager, and many have been fortunate in gaining such development opportunities from training offered later by their organizations or through actively reading articles and books, enrolling in courses, and through continued self-directed learning.22 We heard from many of the leaders that they knew they did not know everything and found it helpful to admit what they did not know, and so they asked questions and consulted with others with more experience. Mentoring Almost everyone mentioned mentoring and its value in helping people grow. Many mentioned their appreciation for mentors whom they encountered and developed helpful relationships with along the way. Some joined external mentoring groups with peers in other organizations, or even other industries, to give them nonbiased feedback and guidance.23 Others sought mentors in their own organizations to offer advice and guidance that fostered their development. Several actively and intentionally mentored others. For example, Darcy Jaffe, MN, FACHE, Chief Nursing Officer at Harborview Medical Center, invites new hires out for coffee to connect with them and offers to have them shadow her to see what an administrator does. This gives these new nurses access to an experienced senior leader and helps shape their vision for possible paths for their own growth.24 Learning to Run the Business of Health Care Be honest about what you do and do not know, and be open to learning from other sources and people to get better at what you do. Do not be afraid to ask questions and admit what you do not know. Build relationships with people in other departments to support you in handling new business areas where you do not have training or experience. For most of us, our clinical education did not include topics on running the business side of a clinical practice with the need to understand

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different insurance reimbursement rates, office overhead expenses, and comply with billing and regulatory requirements. Some figure it out later when they are running their own practices such as dentistry,25 speech therapy,26 or psychotherapy.27 When some went on to work in larger community health systems, they were faced with increasing complexity of multiple public funding streams28 and new organizational dynamics to understand.29 These leaders continue to learn, grow, and contribute, working closely with the teams they manage to continually earn the credibility and respect of followers, peers, and the administrators to whom they report. Accountability for Productivity As Dixie Casford, LPC, MBA, Vice President of Acute Care at ­Mental Health Partners explains, there can be challenges to hold people accountable for doing such required parts of the job while running the business of providing help. She recommends separating therapy from supervision— or, as others have expressed, supervision is not therapy and you are not your employee’s therapist! As a supervisor, acknowledge the difficulty of meeting performance expectations (e.g., meeting a specified number or percentage of work hours providing direct service to clients) and ask, “How can we put the right things in place?” to encourage engagement in accomplishing what is needed to provide help to clients in a productive way.30 Collaboration Enhanced with Nonclinical Disciplines As their career successes illustrate, becoming a manager in health care is not a one-time event but a continual unfolding of growth, responsiveness, and anticipation of change driven by health care needs and requirements in a rapidly changing, tightly regulated environment with uncertain financial resources and extremely thin profit margins. The management perspectives in this book are enriched by several nonclinical people who shared their observations and experience working closely with clinically trained people.31,32,33,34 Such people contribute valuable partnership to the success of health care organizations, especially in hospital systems



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where it is common for top leadership responsibility to be shared in dyads or triads such as a physician in the chief executive officer role working closely with a nurse leader, such as a chief nursing officer with advanced nursing credentials, along with an administrative leader with advanced experience and education such as a master’s degree in health administration or master’s in business administration. Shifting Your Perspective to Systems and Teams In health care, there is particular emphasis on patient safety, access to appropriate treatment, and continuity of care. This may require you as the manager to get involved in designing schedules and protocols that deliver needed, high-quality care to patients while providing the systems, tools, and supports needed by your team members who report to you. As Kenneth T. Bellian, MD, MBA, explained, as a provider you are focused on the needs and expectations of each individual patient. Now, in a leadership position, it requires you to think at a system level and to bridge across many silos or departments to achieve success. This can be especially hard for some people in medicine and health care, particularly if their training was delivered in hierarchical or authoritative cultures.35 Preston Simmons agrees that people need to think differently. Key skills include the ability to bring people together to make success happen. It is a matrixed environment where people need to work with and through others. New models emphasize team leadership, and people need to think differently. Health care delivery operates in teams, which is not taught to physicians in medical school. Older physicians were taught more of a command-and-control approach. The work is extremely challenging due to very complex regulations and razor-thin profit margins.36

Who Can Help? Get a Mentor! There is so much complexity and subtle nuances that you now must master although they were not included in your clinical training. So, it is not surprising that the vast majority of interviewees mentioned the need for others with wisdom to help guide them. When asked what advice they would give other new managers, many replied without hesitation,

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“Get  a  mentor!” Mentors are typically wise people with more experience than you who are willing to help guide you in your development. Sohnen-Moe (2016) explains that they often serve as trusted confidantes to help you assess yourself honestly and figure out what you need to work on to achieve your goals.37 Look for Others Ideally, the person you report to (your boss) provides some of this mentoring support and guidance to help you grow and develop in your role and career. However, there are benefits of finding other mentors and people who can help. One is for candid conversations in which you might want to be more open to admit your shortcomings and weaknesses to someone other than your boss, who is in a position to evaluate you to strongly influence your advancement and rewards. And, as Jeff Zayach, MS, pointed out, it is helpful when you are new to have other people available to help you so you do not have to take every question to your boss.38 Peer-Level Help on Typical Activities Your peers in the organization are a valuable resource to help you learn how things are done in your new role. This can cover your questions about routine forms and typical activities. For example, you might need to ask someone how to handle specific activities such as, “How do I approve time sheets for the people who report to me?” “How do I enroll in seminars offered by other departments?” as well as questions about organizational norms and how things get done, such as, “If you have a technical emergency and can’t reach anyone on the help desk, who do you work with to get it fixed fast?” or, “Is it okay to approach the controller to ask for approval of an unexpected large expenditure if I can’t find the chief financial officer? In your experience, does our director want to be involved in things like that?” Craig Iverson, MA, offered a practical suggestion for working with mentors or other guides, which might include a peer-level “buddy,” another manager with whom you can talk things over and get feedback. He recommends as a first step for new managers to sit down with someone



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more experienced and to develop a list of typical things to anticipate happening so you can be prepared when they do. Having someone to help you work through unfamiliar situations can help you develop your managerial skills as you learn about your options and available solutions to challenges. From his experience as a clinical program manager he offered an example of having several team members asking for the same holidays off when coverage was needed for the clinic. His suggestion was to be prepared with a way of responding, such as prioritizing requests for time off according to seniority.39 Help with Your Professional Development Mentors can enhance your overall professional development by helping you explore options and develop your overall capabilities. You may find mentors in your own organization, or outside in other organizations. Peer-level “buddies” can help you answer specific questions in your work environment, help you anticipate and prepare for expected issues, and guide you to respond confidently and effectively to unfamiliar situations. In your new role, unfamiliar issues will come up for you about your new level of power and influence that will affect your working relationships with your team members and others in your organization. Remember, your clinical skills helped you recognize and respond to others’ needs. These are still important approaches for you to use and build on, and you will need to expand your perspective and learn to adapt in new ways. Take heart, mentors can help so you don’t need to do this alone!

Chapter Summary and Key Points In this chapter, we considered some of the special aspects of working in health care that require you to develop new management skills that probably were not part of your clinical training. You have seen a summary of important themes that emerged from interviews with many different people working in a variety of health care roles and organizations, with their suggestions and recommendations, which we will explore further in later chapters.

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Key Points: 1. Managing in health care is complicated by funding and accountability from multiple sources aside from patients themselves. 2. Health care managers are under increasing pressure to increase efficiency, reduce waste, and improve collaboration and resource management. 3. Shift your perspective from individual patients to developing effective systems of care. 4. Step up and seek new challenges. 5. Get needed training and experience to earn credentials. 6. Be the person others can count on to get things done. 7. Get a mentor to help guide you. 8. Help your people do their jobs better. 9. Apply your skills and prior experience to help things work better. 10. Build relationships, internally and externally. 11. Know what is expected of you, and let others know what is expected of them. 12. Collaboration between clinical and nonclinical staff is enhanced with learning among people who have different training and disciplines. With this introduction, we welcome you to this exciting and fulfilling journey as you too become the most effective health care manager you can be!

Introductory Activities to Get You Started You may use these as group discussion questions or write down your individual responses. These questions can help you identify where you may need to concentrate on skills and chapters in this book. We recommend you develop a file or notebook to keep track of your progress. Do not worry if you do not have all the answers now. You may use this as a baseline assessment of your preparation for management and revisit questions to help you measure your progress as you continue in your management role and your progress through the book. 1. Review the Contents and Organization of the book, above. a. Which chapter with its topics feels most familiar to you and why? What are your top three existing areas of knowledge or



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competency in this area? How do you know how strong you are in these areas—what feedback have you received or other evidence do you have? What other sources of feedback will you get as you advance as a manager in your current organization? b. Which chapter do you have the least knowledge and experience in? How does this topic relate to your current managerial job and how do you anticipate that might change? 2. Consider examples of experience or recommendations from the interviews described in this chapter. a. What ideas would you consider adopting for your own management development? b. What resources could you use for more information (e.g., targeted chapters of this book, people in your workplace or other mentors, books, articles)? 3. What skills or experiences that you developed before your health care management role will be valuable to you now? What opportunities do you see to apply them that will benefit your team and organization? 4. From your experience working in other kinds of organizations and your perspective as a customer of different kinds of businesses, what have you found that is different in your health care organization and the way it runs? a. Consider things such as the reason the organization exists, how it earns money to pay for its expenses, the skills and training of people who work there, special risks and benefits of working there. b. What do these different characteristics suggest that you need to learn in order to succeed as a manager in your health care organization? 5. What relationships would you like to develop to support your team and you in your role? How will you cultivate your contact and collaboration with these people and their teams or organizations? 6. Many of our interviewees mentioned the importance of having a supportive and experienced mentor to give you advice and guidance in your early journey into management. a. What mentors or advisors have you had before? Consider work, school, family, and other activities. How did their guidance help you develop?

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b. What people do you know who might be helpful mentors for you? Think about people with valuable experience who seem willing to help you. What advice would you like from them and how will you approach them? c. What new traits or knowledge in a mentor would be most helpful for you as you transition or develop now into a management role? d. Identify at least two candidates you are already acquainted with who could be a helpful mentor for you as a new or evolving manager. How will you approach them and establish a relationship and dialogue that is mutually beneficial? e. Where could you find mentors or peers outside your organization? Do you belong to or have access to existing groups that could be helpful, such as a professional society for your clinical discipline, former classmates, other groups; or how could you start your own group? What are the benefits of external resources, possibly from other industries (not health care)?

CHAPTER 2

So, Now You Are in Charge! Leading Your Team and Managing When Others Report to You Chapter Overview 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 • Expectation Management Model • Performance expectations • Coaching for performance and development • Performance tracking and planning

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• Performance problems: What to do? • 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. For further information on these and other topics related to work culture, employee strengths, and hiring, please see Chapter 2 in Volume II.

What Is Different about Being a Manager Congratulations, now you are in charge! What has changed for you in your new role? As Ginny Trierweiler, PhD, points out, “When you are a star clinician who is promoted to a manager position, you may go from being the most capable and successful on the job to being uncharacteristically unfocused and disoriented. If you are to become successful in your new role as manager, your top priority is to become clear about your new role and how it differs from your prior role as clinician.”1 Let us step back and consider how your strengths and skills helped you get to where you are now. Probably, like many of the managers interviewed for this book, you earned the credentials needed to practice and lead in your health care profession, accepted responsibility for getting work done correctly, and you sought opportunities intentionally to increase effectiveness in your team or larger workplace. Or perhaps someone else noticed your successful performance and appointed you to an interim role to fill a gap in management. Perhaps you recognize some of these actions and others we heard from those we interviewed and summarized in the previous chapter, and maybe you would emphasize some additional attributes that contributed to your success, such as your reputation for collaboration or talent for innovation. Step Forward and Take Charge “Effective leaders,” Armstrong (2013) writes, “are confident and know where they want to go and what they want to do. They have the ability to



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take charge, convey their vision to their team, get their team into action and ensure they achieve their agreed-upon goals.”2 These actions may require big changes that will stretch you in ways that are not always comfortable! Many of the people I talked with described their initial feelings as a new manager as treading water, learning to be comfortable being uncomfortable, realizing and needing to admit they did not know everything, learning who to ask and where to get information on handling issues they had not dealt with before, all while trying to act confident so the people they supervised would trust in the new manager’s leadership capabilities. Although they might feel disoriented, they knew it was not a good idea to admit aloud, “I don’t know what I’m doing!” In surveys reported by Horstman (2016), many new managers in various industries described their experience like this: “I got promoted, and they didn’t tell me anything about what I was supposed to do or how I was supposed to do it. They just gave me a team and wished me luck.”3 It is no wonder that many new managers feel overwhelmed and underprepared! Let us start by identifying your managerial activities and clarifying your responsibilities to help you sort this out. Clearly understanding the new rules and tools you will be working with can build your confidence and success as a new health care manager. What Do Managers Do? Armstrong (2013) explains what management is and what managers do: “Management is the art and science of getting things done. As a manager, you are there to get things done through people . . . . You decide what to do and then ensure that it gets done with the help of the members of your team.” He further explains that people are the most valuable resource and that managers are ultimately responsible for the management of all resources. As a manager, it is your responsibility to ensure that your people have the tools and support they need to meet the requirements of their jobs.4 This does not mean you need to be available constantly to answer every question and tell them what needs to be done; rather, you need to direct them and help them figure out where to get the information and skills they need. Often, you need to get actively involved in removing barriers to their work, especially because you have decision-making power,

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influence, and authority that they may not have access to in their positions. Your ensuring that they can be successful in meeting the requirements of their work is an expected part of your manager role. Typical management activities include supervising people who report to you, using data and reports to monitor team progress on key performance indicators, leading meetings, planning and budgeting, hiring and ensuring successful performance of your staff, resolving problems that affect patient care, and handling barriers that interfere with individual or team performance. Responsibility for the Work of Others Essentially, you are responsible not only for the work you do, but also for the actions and results of those who now report to you. Christina Loetscher-Whetstone, BSN, RN, Director of Nursing at the Mental Health Center of Denver, described her new elevated level of responsibility as “worrying about 30 other licenses. It’s easier to worry about just me, but that’s not what I signed up for.”5 Horstman (2016) identifies four critical behaviors of managers: 1. Get to know your people. 2. Communicate about their performance by giving them feedback. 3. Ask for more to stretch them and help them grow. 4. Delegate, handing work down to the people who report to you. We will look more closely at all of these items as we progress through this chapter. As you take charge, you will need to assign some of the things you were doing to the other people who now report to you, and be alert to when it’s appropriate to delegate activities rather than do ­everything yourself. Let us look more closely now at delegating, its benefits, and how to do it effectively.

Delegating Responsibility to Others Delegating involves getting things done through other people. Although managers must delegate many activities to their team members, they still



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remain involved and accountable. As Armstrong (2013) observes, “You can’t delegate everything.”6 Horstman (2016) advises, “If you’re a manager, your key to long-term success is to master the art of delegation.”7 By delegating, you free up your time for work that only you can do because it requires your level of skills, experience, and responsibility. “Delegate, but you can’t abdicate,” warns Ruth King (2013). Even though you have asked someone else to perform the actual work, you still have responsibility for the overall results.8 So, there is more involved than just passing work to others and forgetting about it. There are some important things you need to establish to support the successful completion of the work and the development of the employee performing it. When handled appropriately, delegation helps you lead more effectively by developing your skills to focus on the most appropriate and impactful things, and it builds the capabilities of the people who report to you and the overall value of your team’s contributions. How to Delegate Ensure your employee accepts and understands that the responsibility has been transferred to her, that she is committing to own it and complete the tasks. Horstman (2016) offers these guidelines: 1. State your desire for help. 2. Explain why you are asking that person to handle this activity. For instance, does she have special skills, or is the activity part of the responsibilities she has or wants to take on? 3. Ask for specific acceptance. 4. Describe the task or project in enough detail that she knows its purpose, status, what she needs to do with it. 5. Communicate the deadline, quality measures of success, and reporting standards. This model is based more on relationship power and persuasion rather than on role power and giving orders. When you request help, your employee could say no, but it is more likely she will say yes. This moves her

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energy from mere compliance to commitment, which makes her more energetic and effective.9 Here is an example of a conversation for you to delegate to your employee, following the steps above. 1. “Carmen, before I became the manager, I was running the support groups for family care givers. I want our team to continue to do this because our patients’ family members need and value such support. I need help to make sure we provide the attention these people need.” 2. “When I thought about who could handle this, I remembered you told me you enjoyed working with families, had extra training in group work, and wanted to offer more group resources for the people we work with.” 3. “Would you be willing to take over running these groups and work with me to transition the responsibilities from me to you? What information and support do you need from me to handle this successfully?” 4. “Currently I do the groups every Thursday morning. You’ll need to make sure the meeting room is scheduled through the end of the year, make sure patients have designated and approved our contact with their family members, and invite them. Here is my outline of what is covered. Please review it and meet with me to talk about what you’d like to add or change so you’re comfortable in how they’re covered.” 5. “I’d like you to start running the group yourself in three weeks. Let’s schedule time in the coming week to review your ideas and plans. When you run the group, be sure to document who shows up and what was covered so we can submit for billing and track in our patients’ records for follow-up support. We survey group participants and review their satisfaction and feedback so we can ensure good quality. You and I can review the results in the first three months and talk about your ideas and suggestions.” Helping Others Become More Effective A manager’s job is to make others more effective so they can solve more problems, rather than all the problems coming back to you. As many managers explained in their interviews, this requires that you learn to



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trust your people and expect that their approaches will differ from yours. Chris Radigan, LCSW, admitted there was a challenge in letting go and allowing others to do things in their own effective ways.10 Jeff Tucker, VP of Human Resources at the Mental Health Center of Denver comments that delegation involves being satisfied with something different from the way you would have done it. He recommends giving people the objectives you need them to achieve and the parameters they have to work with, then expect them to achieve the results in their own way.11 In the example above, the manager asks the employee to think about changes and offers to help her plan to implement the changes effectively. Freeing Up Your Time In freeing up your time by delegating, Dobson and Dobson (2000) suggest that you find someone who already knows enough about how to do the delegated work so you do not need to provide much supervision on their handling of the task. Yet, a key reason to delegate is to develop the skills of others. Be prepared initially to spend more of your time and effort while the person is learning and the quality might not be up to what you could do yourself. Recognize that as a normal part of the learning and development process. “Provide the training, support, and encouragement over time to help someone grow and develop to the point that they can take on the assignment and make it their own.”12 In later sections, we will help you learn to coach the people who report to you so you can help them set goals. As you develop the habits of providing feedback and the routines to conduct coaching, you have the supports in place for you to delegate effectively. Later in this chapter, we will look at how you can communicate to earn the trust of others because they know what to expect of you and what you expect of them.

Power and Trust in Your New Managerial Role Building a Foundation Think about how you arrived in your new management role: were you promoted from within or hired externally? D.C. Dugdale, MD, reminds us to meet with each person. “Learn their pain points . . . . There is no

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substitute for face-to-face (interaction versus e-mail).” It is also important to recognize this main difference of situations between “A group that’s been waiting for a leader versus one that doesn’t think they need one.” You might need to build more groundwork with the latter.13 Using Power Effectively Elvira Ramos, Vice President of Programs and Inclusive Leadership at the Community Foundation of Boulder County, describes effective use of power as a balancing act between being too soft and too tough. You need to make hard decisions and take responsibility for them. She suggests that sometimes you need to say, “Well, I’m the boss, and this is what we’re going to do.” She reminds us that as the leader, you do have power and it can be reassuring to staff; use it in a way that is kind and helps your team members do their jobs. And you are the one to take the heat for your team’s mistakes.14 Such interactions help build mutually supportive relationships between you and your team members to position your team to successfully achieve organizational goals. Driving Action by Aligning with Values You have the power to communicate vision and set direction. As a manager, you need to look up and out to communicate strategic vision that helps people focus on successful performance and cost-effective operations to make maximal use of the revenue and health care funding available, while you will likely have little direct control over the structure of the health care funding mechanisms and associated rules for administering them. This can require a tremendous amount of judgment and communication to balance external interests with the motivation and values of clinicians, who really want to help their clients. Applying their clinical values, training, and judgment may seem to conflict with external requirements. Complying with External Requirements Kristi Mock, LCSW, Chief Operating Officer at the Mental Health Center of Denver, recalled the challenges of operating under a class-action



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lawsuit in the 1990s that required major restructuring of clinical service teams and externally prescribed amounts of service hours that were closely tracked and strictly enforced by an externally appointed court monitor.15,16 Her steady approach in engaging and communicating with clinical teams kept them motivated to ensure clients received high amounts and quality of care. On the administrative side, she instilled high performance and accountability in delivering the required reports to state government officials. Her ability to manage and balance these different interests led to the successful completion of the terms of the class-action lawsuit and its eventual dismissal, along with an enduring appreciation among clinical staff for the value of productive allocation of their time to direct service activities that help their clients get better and ensure ongoing financial health for the organization. Internal Operating Efficiency and Core Clinical Values Jen Leosz, LCSW, VP of Clinic Services at Mental Health Partners, is another highly respected and effective leader who rose through the clinical ranks from a therapist providing direct clinical service to an executive management position overseeing clinical teams and senior clinical directors. When her organization needed to boost its operating efficiency to ensure its sustainable financial health, Jen wisely recognized and aligned with the clinicians’ core service values. Clinically trained people become therapists in community mental health centers because they want to help people lead better lives; they are not driven by a primary interest in financial issues. Thus, she explained to her clinical teams how increasing their productive time with clients led to increased availability for seeing more clients, which improved clients’ access to care and reduced delays in their getting needed treatment. Clinicians understood and supported this reasoning, and so they were able to appreciate how increased efficiency and financial health ensured sustainable access and services that would continue to benefit clients.17 Accountability and Feedback on Progress As these examples illustrate, clinicians who transition from direct care to manager roles have opportunities to leverage their clinical skills and

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values. They apply their ability to get things done to a broadened scope that includes administrative and leadership arenas. In addition to setting direction for their teams and organizations, they develop abilities to motivate others, hold them accountable for performance, and provide feedback and coaching to help them succeed. Both Kristi and Jen obtained data and reports that they shared with managers and teams they were responsible for to set performance targets and provide needed supports for their teams to meet their goals. Involving People to Enlist Their Commitment Jackie Attlesey-Pries, MS, Chief Nursing Officer at Boulder Community Health, described nurse staffing and scheduling as a critical issue because of the need for continuous coverage for hospitalized patients. It is challenging for managers to construct schedules that ensure adequate coverage for patients and are perceived as fair and workable for clinical team members. She found it most effective to clearly communicate the coverage needs and scheduling goals, and then involve the clinical nursing staff in building schedules they could support.18 Craig Iverson, MA, offers another example involving a former peer-level teammate who had confided that he was not completing his documentation correctly. Now as that person’s manager, you need to hold him accountable. Craig suggested initiating an honest conversation with the person to acknowledge that you are aware of what he is struggling with and to ask for his ideas and commitment on how he plans to improve.19 Professional Relationships with the People You Manage Now that you are a manager, what kind of relationships should you have with the people you manage? Is it okay to be friends with them? Consider that there could be times when you will need to address performance problems or even terminate people who report to you. Several authors offer examples of why you should not be friends with the people who report to you. Horstman (2016) describes obligations of friendship, which contain foreseeable hazards for both the manager and the person reporting to her. For example, as the manager, you might be



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aware of and feel obligated to warn your friend about imminent budget cuts and layoffs that could affect him, or you might feel loyalty to protect your friend from being laid off and lean toward selecting someone else for elimination, leaving others with perceptions of favoritism toward those you are friends with.20 You need to be fair and not accept worse behavior from friends than from the rest of your team members who report to you. Dobson and ­Dobson (2000) suggest, “Focus on the difference between being ‘friendly’ and being ‘friends.’ Friendly behavior is positive, cheerful, courteous, interested behavior that need not be restricted to people who are actually your friends. Friendly behavior is showing that you are aware of and have concern for someone else as a human being. Stay aware of personal relationships and how they interact with professional relationships . . . . You don’t ever want to be unaware of the significance others may read into them.”21 Managing Resistance It is not unusual for new managers to encounter some resistance and testing from their new supervisees, especially if they had worked together as peer-level teammates. Amanda Daniel, LPC, Program Manager at the Mental Health Center of Denver, shared an example of a new manager who found that a team member suddenly “forgot how to do” parts of the job, such as clinical documentation, that she had previously mastered. This seemed to be a test of the limits of what the new manager would tolerate. The new manager approached this calmly and nonjudgmentally by talking to the team member about the expectations for completing documentation, verifying that she understood and had what she needed to complete the task correctly. The manager expressed confidence that the team member could competently perform the task, which she had been handling successfully in the past. This direct and supportive approach resolved the problem.22 In another example, an RN who progressed from charge nurse to a unit manager in a hospital reported that most of her team knew she was in charge—except for one person. She talked directly with that person to correct the problem immediately before it could grow into a bigger issue.

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Acknowledging Others You Have Been Promoted Over Shari Harley (2013) recommends that if you were promoted and now your former coworkers and peers report to you, you have an individual conversation with each of your new direct reports. Allow them to talk about what it is like for them to be reporting to you now, how that changes the relationship between you, and any disappointment they may feel if they wanted the position themselves. Being candid to talk about what people might be thinking and saying can earn you respect from those you now manage and helps strengthen your relationships with each of them.23 There are some particular challenges for some people who are promoted internally, especially if they end up in charge of people who trained them early on. David Bachrach, MBA, FACMPE/LFACHE, offers an example from an academic medical center, where someone promoted into the position of department chair might need to encourage a highly paid senior (tenured) faculty member to step aside. This would require understanding the person’s needs and handling them sensitively. Perhaps you could offer that the person will still be included in departmental activities and have a place to go, such as office space and access to libraries and resources. Then you would need to be direct and factual about what the organization cannot sustain, such as continuing to pay salaries at the same high level that people earned when they were seeing patients, teaching, and researching, because when they are no longer conducting those activities they are not generating the revenue associated with them. On the other hand, if you were an external candidate, you may need to have a crucial conversation to acknowledge others who applied for but did not get the position you were hired into. Respect them and their needs, which could include looking elsewhere.24

Addressing Escalating Disrespect So, what if you have followed the advice above, spoken directly with people who report to you, listened to their perspectives, yet problems persist or escalate? Some situations require swift and firm action from you. Patterson et  al. (2012) recommend showing “zero tolerance for



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insubordination” or “over-the-line disrespect.” Speak up immediately to catch and address the escalating disrespect before it turns into abuse and insubordination. Tell the person what behavior you are observing, such as raising his voice or leaning toward you aggressively, and that it seems disrespectful to you. Let him know that you want to address his concerns about a content topic (e.g., staff scheduling), but it is difficult to do so when he is showing disrespect or other disruptive behaviors.25 If disrespect escalates to insubordination, get help if you need it from your human resources team, who can help you identify goals for the employee, create a specific plan, and stick with it. Make sure the plan for the employee’s improvement has benchmarks, timelines, and check-in points so it is clear whether the person is making the required progress or not. As Kathleen Winsor-Games advises, “Establish consequences and rewards and carry them out.” It might still be possible for the employee to work toward goals that are beneficial to your team and organization, so do your best to support that. But, if the employee decides not to cooperate, “be prepared to take the next steps, including termination.”26 Or you followed Harley’s (2013) advice and talked individually with your former peers who now report to you, and months later one of them is still resisting your managerial authority. You have had repeated conversations, and still she refuses to take direction from you and continues to ignore your feedback. What else can you do? First, make sure you consult with your boss and human resources department and you have their support. Then, Harley recommends you open the conversation with your intention to talk about your working relationship. Remind the person that you have talked about how you want a good working relationship with her and your observations that she is still resisting you as her boss. Tell her the behavior has become a performance issue: the employee either needs to accept you as her supervisor or find another job. Allow the person to talk. Then end with a suggestion or request to let her know you would like her on the team if her behavior toward you changes; if not, the next step is a transition plan out of your team. This is an example of a challenging conversation that would be necessary to preserve your successful leadership of your team. Similar situations occur when people have been given feedback repeatedly but nothing changes. In those cases, you need to continue to

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address the undesired behavior every time it occurs. Eventually, the person will tire of the conversations and either change or find a different position.27 Managers I have known have reported that they wished they’d had such conversations sooner because when they finally did, they experienced improved team functioning and improved their own performance with increased focus on important priorities. Gaining the Trust of Others Be aware and prepared to cope with resistance if several other people actively applied for the management position you were selected to fill. Sometimes the tension intensifies if you were hired from outside the organization and there were several internal candidates who were not chosen, and now they report to you. Winning them over can take some intentional effort and persistence as you work to earn the trust and confidence of those you supervise, practice dealing with conflict constructively, and become clear and direct to assertively face, rather than avoid, difficult conversations. In Chapter 1 of Volume II, we will look more closely at how to handle conflict. A good start is to listen to others and understand their values and viewpoints so you can encourage their involvement as you build your credibility and earn their support.

Setting Expectations and Communicating Them Helpful advice about expectations was repeated throughout many of the interviews for this book and in our discussion above, about managing up: “Know your boss’s expectations of you,” and managing down: “Be clear in communicating your expectations for the people who report to you.” And, do not forget about the expectations of other people all around you! Expectations for You and Your Team A special characteristic of the health care industry is that the industry’s payment models and regulatory requirements are often based on safety and ethical concerns to prevent harm to patients. This extends the scope of external “customers” beyond the patient as the recipient of treatment



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services. So, in addition to internal organizational policies and goals, and the specific priorities of your boss, you and your team are probably accountable for meeting the requirements established by external organizations that pay for patients’ treatment and monitor for safety and effectiveness of these services. Information is expected of you from insurance companies, public funding sources such as Medicare and Medicaid, and governmental agencies that directly oversee funding and service quality. Information such as clinical outcomes provides evidence of effective patient care and treatment. Other information reflects your team’s performance and compliance with the standards and requirements laid out in the contracts between your health care delivery organization and these administrative entities. Table 2.1 provides an example of a brief, simplified set of requirements with representative items for illustration: Table 2.1  Example of expectations

Requirement

Required by

Target

Performance (most recent quarter)

30-day readmissions

CMS

10%

8%

Heart failure mortality

CMS

13.2%

15%

Inpatient length of stay, average days

CMS

3

2.4

Patient satisfaction score

Private insurance contract A

99%

95%

Time to first follow-up appointment (days)

State requirement

7

6.2

Clinical productivity

Internal operations

65%

59%

Claims denials

Internal finance

4%

2%

Patient information accuracy

Internal quality

100%

93%

Open positions: days to fill (average)

Internal human resources

22

18

As a Learning Activity at the end of the chapter, you will have the opportunity to complete a table like this that represents the actual requirements and standards you are expected to meet in your organization.

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Understand and Communicate What Is Expected of Your Team It is important to make sure you have a clear understanding of the standards and contractual requirements you and your team are expected to meet such as timeliness of documentation, number of patients served in contractually specified categories, and content of documentation for specified events such as patient admissions, transfers, response to treatment, discharge, adverse incidents, and so forth. Depending on your position, you may or may not have direct contact with external site reviewers and auditors; those visits may be handled directly by your quality or compliance department, but in any case, you and your team are still accountable for supporting your internal colleagues who interact directly with external customers who monitor your organization’s performance to these standards. Actively identifying these expectations and requirements up front can help you manage time and energy proactively. Your team members will appreciate the opportunity to plan and organize their time so they can deliver their best work rather than reacting to a barrage of short-notice requests to respond to external requirements that were not visible enough to be included in their planning and scheduling of the work they need to get done. How to Communicate What You Expect It is your responsibility to tell your team members the behaviors you expect of them and to make sure they know the performance requirements they are expected to meet. Of course, if you are proactive in establishing and communicating your expectations before problem behaviors arise, you increase the chances of your team members performing well and the people you manage coalescing into an effective team. To develop cooperation and commitment of your team members, remember to explain how expectations and standards support your teams’ goals and alignment with the organization’s mission. As many interview participants mentioned, it is important for them and their team members to understand why they are being asked to do things in specified ways. Explain Why It Is Important For example, adherence to correct formatting of monthly reports can seem like an annoying detail until people understand why it is needed.



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Typically, such reports are collected from a larger number of teams, results get synthesized and distributed to higher levels or to external audiences that can award rewards or impose penalties. And it is beneficial for the team to demonstrate to the organization’s executive team and board of directors the team’s valuable contributions to organizational goals. This helps your team earn a positive reputation for high-quality work to gain the support and resources needed for continuing success. Be clear and specific when you communicate your expectations and intentions in areas such as the following.

Decision-Making Latitude Tell the people who report to you what you expect them to decide for themselves, and at what level of financial expense or seriousness of a problem they need to ask for your approval. Examples: “If you’re scheduled to be doing nonclinical administrative work and you need to be away from the clinic, you don’t need to ask my permission, but please let me know where you’ll be and how I can reach you if needed.” “If you are with a patient who needs help beyond your clinical scope of practice, and the situation isn’t covered in our clinical protocols, or you aren’t sure of the best course of action, don’t struggle with this alone. Please contact me or our designated on-call senior clinician for guidance to determine what to do.” “We have an allotted amount of bus tokens for patients who lack financial resources. Please use your judgment in offering them to those who truly need them. You may also authorize taxis for those whose insurance plans cover this. For noncovered transportation expenses, please ask me for authorization before charging the expense to our clinic’s budget.” Standards and Due Dates Tell people the standards for tasks and timing such as written progress reports and their format. For example, “Please send me a progress report of your activities by the 20th day of each month. Here is the format I need everyone to follow so I can review your input and compile what I need to send to our director and report to our compliance team for our facility accreditation and licensing requirements.”

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Expected Levels of Performance Find out and make sure your people know the levels of performance expected by the organization in key indicators such as patient satisfaction, health care measures such as HEDIS scores, percentage of time dedicated to direct patient services, cost measures, and other things measured by the organization that you and your team are accountable for delivering. When people know what they are expected to accomplish, and receive ongoing feedback on how closely they are attaining the established goals, they understand what their level of performance is, so there should be no surprises later when you conduct longer-term performance reviews with them. Other Behavior Be clear about the behaviors you expect in the workplace such as starting meetings on time, complying with company policies, notifying you and other team members of absence from work, supporting other teams when needed, and so forth. Many of these things are not numerically measured performance but you do observe when desired and required behaviors are happening, and when they are not. Clarifying such expectations supports accountability—how can people be accountable for doing something they did not know they were supposed to do? And when they did know but chose to not conform to expected behaviors, then it is fair for you to administer reasonable consequences.

Accountability Without Fear and Blame We also need to set expectations for supporting a work culture which values doing the right things for the safety of our patients. It can be challenging for people to speak up when they are aware of errors or unsafe practices. On one hand, we need to be cautious about unduly punishing people for making honest mistakes. Maybe a nurse followed the required procedure, but got a bad outcome. Or something outside her control prevented a doctor from completing a procedure correctly. On the other hand, we cannot condone deliberate disregard of best clinical practices or deviation from company policies.



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Fostering an environment of open communication, with the ability to look at mistakes without blame, can build trust within your team that leads to improvement in systems and processes supporting patient care. A surgeon described by Sutton (2010) reflected on problems he had experienced in his own medical training because of the harsh and disrespectful ways medical staff members treated those less senior. He concluded that “respect was important for reducing medical mistakes because nurses and residents need to feel safe—even obligated—to point out errors made by him and other senior physicians without fear of retribution.”28 For people to feel safe and empowered to speak up when they see things being done incorrectly that can adversely affect patient care, there must be trust and respect to identify problems and for people to feel confident that they will be listened to. Michael Ward, MD, led a roundtable discussion in a health care operations management conference in 2018, on how patient outcomes are impacted by coordination and communication within teams.29 In a conversation before his session, we talked about the importance he sees in empowering everyone on the clinical team to share perceptions openly, without regard to professional rank, so everyone’s input is listened to and valued in the context of the continuum of care for patients as they move through different areas of care delivery. Fair and Just Culture Consider the approach of “Just Culture” developed in health care organizations. Several of the nurse leaders I spoke with, such as Jackie Attlesey-Pries and Darcy Jaffe, champion it in their organizations,30,31 and Annette Cannon has presented a poster session about it in her nursing conferences.32 As they explained, it prevents medical errors and emphasizes accountability without unjust blame. In such a culture, people are expected to do the right thing. If they make errors or are aware of them, they are expected to be accountable by communicating and correcting problems. The emphasis is on high standards of care delivery to patients and being responsive to potential problems that get in its way. Trust and belief in people’s dedication to practicing responsibly and ethically de-emphasizes personal blame when often it is a system that is faulty. Of course, with accountability, health care practitioners do take responsibility for their mistakes and work hard to prevent and correct them.

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Psychological Safety in the Work Environment Frankel, Leonard, and Denham (2006) describe a fair and just culture as “one that learns and improves by openly identifying and examining its own weaknesses. Organizations with a Just Culture are as willing to expose areas of weakness as they are to display areas of excellence . . . . Each individual feels as accountable for maintaining this environment as they do for delivering outstanding care. They know that they are accountable for their actions, but will not be blamed for system faults in their work environment beyond their control .  .  .  . They are accountable for developing and maintaining an environment that feels psychologically safe.” You play a key role in building such a culture in your organization when you ensure that every employee clearly understands her own accountability and you lead by example in practicing such accountability yourself. People feel respected by everyone in every work interaction they have.33 Reporting and Tracking for Quality Improvement Your organization’s reporting practices for critical or adverse incidents can support your fair and just culture. Clearly communicating policies and expectations for reporting incidents instills accountability and shared responsibility among everyone for maintaining a safe and effective workplace. Categorizing types of incidents and tracking data supports systematic review of patterns and trends by objective committee members. Regularly occurring internal reviews should be protected from external examination to allow the organization to assess its mistakes honestly and openly. Regular, systematic review of categories of incidents that occur frequently can shed light on opportunities for improvement to work systems. For example, medication errors might be caused by unclear labeling or packaging that are not necessarily the fault of the people administering the medications; however, these people should take responsibility for speaking up about their observations and experiences of what is not working. Patterns that show frequent errors by specific locations or individuals should be looked into to determine possible causes. Are there training issues, different procedures among locations, understaffing and overscheduling that affect error rates but are not within the control of the individuals making the errors? Or are there individuals making errors that they need to accept responsibility for correcting and avoiding? As a manager, it is helpful



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for you to focus on expectations and standards you need to hold people accountable for meeting, and help them get there. Figure 2.1 is an Expectation Management Model that shows how expectations drive performance. The model shows expectations in the context of performance. The outer circle represents expectations, with actions to first identify objectives or behaviors that are the focus of work activities, and then to specify the target or desired level of performance in these objectives. The inner circle represents actual performance, which will be measured and compared to the specified target or desired level to evaluate whether and to what extent the expectation has been met. Then calibration occurs to adjust performance, and recalibrate objectives and targets if needed. Steps in Setting and Managing Expectations for Behavior and Performance 1. Identify the activity, behavior, or objective to focus on. These can be the behaviors and activities you expect of your team members, or quantifiable Key Performance Indicators. 2. Specify the target level of attainment. This sets your expected standards for performance. The target can be specified numerically or described in terms of desired observable behaviors. 3. Measure the actual level of performance. This could be numeric (metrics) or qualitative and subjective assessment through observation. 4. Evaluate whether the actual performance meets, falls short of, or exceeds the expected standard level. Also consider whether the target level is realistic and appropriate, not too easy or impossibly difficult, and whether the focus and objective are still appropriate. 5. Encourage performance adjustment if needed, and recalibrate objectives and targets as appropriate. 6. Continue to measure performance and facilitate adjustments as needed. Example of Applying the Model Community mental health centers across the United States require clinicians to spend a specified number of hours per month or percentage of their work time providing direct care and services to clients, as shown in Table 2.2. Each center establishes an appropriate standard that supports

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Figure 2.1  Expectation Management Model



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Table 2.2  Example of applying the Expectation Management Model Step

Application

1. Identify the activity, behavior, or objective to focus on. These can be the behaviors and activities you expect of your team members, or quantifiable Key Performance Indicators.

When I arrived at Mental Health Partners, a high-priority focus of performance was dramatic increase in clinicians’ performance in reaching Direct Service Expectations for the percentage of their working time providing direct care to clients.

2. Specify the target level of attainment. This sets your expected standards for performance. The target can be specified numerically or described in terms of desired observable behaviors.

Initially, the target level of attainment was 100% of clinicians, in all types of programs, to reach 65% of their time in direct services with clients.

3. Measure the actual level of performance. This could be numeric (metrics) or qualitative and subjective assessment through observation.

Measurements were obtained from services tracked in the electronic health record system and from the payroll reporting system. This showed that most outpatient programs were steadily increasing their direct service time percentages from one quarter to the next. Other specialty and community-based programs showed lower percentages and slower rates of increase.

4. Evaluate whether the actual performance meets, falls short of, or exceeds the expected standard level. Also consider whether the target level is realistic and appropriate, not too easy or impossibly difficult, and whether the focus and objective are still appropriate.

Evaluation with clinical leaders reviewed performance of different teams relative to targeted direct service time. Examination of different types of programs and funding streams revealed that there were many special contracts with funders that had individual rules for tracking time and services.

5. Encourage performance adjustment if needed, and recalibrate objectives and targets as appropriate.

a. It was appropriate to adjust expectations to align more realistically with the actual operating requirements of different types of programs and services, especially for communitybased programs that required clinicians to travel throughout the day to get to the clients that they met with directly. b. In many cases, there were contracts that compensated directly for travel and other overhead costs, so it was appropriate to expect and recalibrate to a lower amount of direct service time for clinicians working in such programs. (Continued )

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Table 2.2  (Continued) Step

Application

6. Continue to measure performance and facilitate adjustments as needed.

a. Targets were recalibrated for different types of programs and progress was measured against the appropriate target for each team. b. Performance reporting systems were enhanced to reduce the amount of manual calculations that are needed to determine actual performance. c. Team managers were given access and training to monitor their teams’ performance. This facilitated ongoing communication with their team members to identify and remove barriers to performance, and to inform and negotiate with higher-level managers if further adjustments were justified.

the organization’s generation of billable services to payers and ensures that clients and patients have timely access to the clinical care they need. Typical percentages of direct service time range from 60 to 75 percent of work time. This allows for necessary time for non-billable coordination, documentation, and administration that is necessary to support the direct care. Notice how these steps support critical areas we covered earlier to communicate expectations and instill accountability for meeting them. Measurement and discussion about what is being measured helps adjust for fair goals that can realistically be attained. The open dialogue between managers and team members identifies opportunities for improving the quality of work and the systems, such as tracking and reporting capabilities, that support the people who are doing the work.

Performance Expectations Define Performance Standards and Help Employees Achieve Them Darla Schueth, RN, MBA, retired CEO and President of TRU Community Care, shared an illustration from her early experience as a new nurse supervisor conducting performance evaluations. Darla discovered that nurse Maria had a different view of her own performance than that



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of her supervisor, Darla, who needed to provide honest feedback in a way that would motivate rather than discourage her supervisee. Rather than berate the nurse for her performance deficiencies, Darla decided to create a shared vision of good performance and communicate her commitment to supporting her employee’s growth and development by telling her, “You can be what you think you are and I will help you get there!” They talked and came to agreement about what good performance looked like, and Maria accepted Darla’s feedback on what she needed to improve, which was timeliness of documentation. “She owned it!” Darla reported, “And in six months she earned the raise we’d agreed to for her improved performance.”34 Word Pictures for Clear Understanding Darla’s story reinforces advice from Mark Murphy (2017), who recommends that when we see things differently from others we work with, we start a conversation, not a confrontation, because confrontation only invites resistance. Conversation eliminates blame, can help to reassure the other person that you want to look at the situation to get on the same page, and opens the door to agreeing to a plan, which helps the other person feel in control.35 Murphy recommends making expectations completely clear to employees by creating what he calls “word pictures.” It is not enough to tell employees generally that they are not doing a good or good enough job; you will never close the assessment gap between your views and theirs if you have not identified exactly what subpar (bad), good, and exceptional (great) performance consists of. “A word picture is a shared definition that uses concrete language with examples of three levels (of performance): bad, good, and great.” As Murphy explains, “When everyone has a different definition of the truth, an argument is virtually guaranteed. And far too many disagreements occur because we don’t have a clear and shared definition of the truth. A Word Picture .  .  . transforms abstract concepts into concrete examples that anyone can understand . . . . People understand abstract concepts faster and better with examples that teach how to do something well, how not to do something, and how to do that something incredibly well. It is also beneficial to use concrete words, phrases, and sentences, as

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they are found to be more comprehensive, memorable, and interesting than abstract language.”36 Use Relevant Examples of Standards Show examples based on the standards most relevant to the clinician’s setting and responsibilities. For instance, in acute hospital settings the treatment team needs immediate access to current information about the patient, including brief but complete and accurate records of patients’ vital signs and readiness for discharge. Exceptional or “great” documentation might add other information, assessment, or cues that support excellent coordination and care delivery for patients, with helpful aftercare plans. So, for clinical documentation, you could review with clinicians the specific standards for timeliness and content needed in the particular health care setting you work in. For example, some outpatient organizations require that all documentation of patient services be completed in the electronic health record within 24 hours of service and treatment plans need to be reviewed and updated every 6 months according to very specific standards. Show clinicians examples of “great” or exceptional treatment plans and point out what differentiates them from ordinary ones; perhaps the “great” ones show clear evidence of patient involvement and are designed to measure clinical outcomes efficiently. Performance Scale Example For example, in an outpatient clinic, you could develop agreements with the staff members who check in patients by comparing actions along a performance scale from bad to more helpful, as shown in Table 2.3. Pick two or three illustrations in each column that are relevant to the employee and his job. An employee can identify where she falls along that scale and what she could do instead, or even how to make a strong performance even better. This approach can help when there are problems with areas that have not been defined specifically. A manager who wanted to get rid of someone because he has a “bad attitude” could reframe the conversation to focus on the specific behaviors that illustrate helpful or problematic attitudes when helping patients.



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Table 2.3  Performance scale example Bad performance

Good (expected)

More helpful

• Leaving your check-in station unattended • Ignoring patients when they arrive • Engaging in personal phone conversations while a patient waits for your attention • Continuing long conversations with others without acknowledging the patient’s presence • Avoiding eye contact with patients • Responding to patients’ questions with silence or “I don’t know.”

• Greeting patients when they arrive at the desk with, “Hello, how can I help you today?” • If you’re finishing a phone call, making eye contact and smiling, letting the patient know you’ll be right with her • Completing the patient’s check-in within 2 minutes of her arrival • Verifying patient’s contact information and payer source • Answering patient questions promptly • Directing the patient to the waiting area

• Asking the patient if she’d like water or a magazine while waiting • Asking the patient if she needs any information or assistance • Providing requested assistance or finding her someone else who can • Showing her how to complete forms or other registration tasks • Offering other help that the patient might need • Checking in with waiting patients if things are running late to offer reassurance

Examples of Measuring Performance to Standards When you define what people are expected to do, and communicate the required amount or level to be achieved, you can measure their performance relative to meeting the established standards. Table 2.4 provides examples of what some interviewees have measured relative to standards. Table 2.4  Examples of measuring performance standards Interviewee

Role

Measured

Rationale

Mary Ellen Benson

Manager in Physical Therapy

• Time to patient’s discharge • Improvement in patient’s level of functioning

• Patient-centered. • Efficiency • Value-based

Lucille Johnson Campbell

Manager in a business setting

Attendance

Efficiency, employee commitment and engagement

Trista Ross

Manager of Pharmacy

• Attendance • Productivity: number of prescriptions filled

Factual and objective basis for performance discussion

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Lucille explained how standards helped her manage performance. “When you’ve communicated what you expect and you’re consistent about not accepting excuses, people either improve in deficient areas or some choose to resign.”37 Performance Feedback Now that you and your employees have clearly defined what high performance looks like, how can you help them perform at the desired high level? Most organizations require an annual performance review, according to a standardized format and approach. And it is common practice for new employees to have probationary periods for their first 3 or 6 months, with assessments to confirm that they are on track and making expected progress in learning and succeeding in their new positions. These formal assessments do provide the opportunity to provide feedback, recognize employees for their successes, encourage them to continue successful approaches, discuss needed improvement, and find out what employees want to develop and accomplish. But are they frequent and soon enough? Feedback to Cultivate Development Ken Blanchard and Spencer Johnson’s advice in an updated version of their ever-popular book, The One Minute Manager (2003), is to notice when people do things right and let them know immediately. Especially when employees are new in their roles, frequent positive feedback can shape their behavior in growing into the full competency they need to attain. The flip side is that you also need to let people know when they do something wrong, in a constructive way that lets them know you believe in them and support their success. These authors recommend that you criticize the action and support the person in a way that helps him get on the right track. The idea of being a “one-minute manager” is to do such high-impact things in a focused and succinct way. Because you do not need to schedule long conversations, you can more easily conduct these conversations briefly and promptly.38 Dale Carnegie (1981) recommends you offer praise and sincere appreciation to other people. If someone who reports to you makes a mistake, Carnegie recommends that you allow him to save face. Use encouragement



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so the person has confidence in his ability to correct deficiencies or mistakes. When you understand the motivations of other people, it helps you enlist their cooperation and commitment to doing what you suggest, particularly when you are asking questions to elicit ideas rather than giving orders.39 Your noticing and communicating with the people you supervise about both their successes and areas that need improvement signals to the people you supervise that you care and are invested in helping them to be successful. When you do this frequently, immediately, and supportively, you foster your employees’ development. Be Clear and Specific When giving feedback about performance, it is important to be specific so the person knows exactly what she did well or needs to improve. If you merely mention to an employee, “You’re good at making people happy,” she does not know much about what she is doing well, whether you are referring to coworkers, patients, or others. She might be wondering what you have seen and appreciated and might be less likely to repeat what she actually did that you found so effective because she really does not know what it was. Notice the difference in saying this instead. “Kirby, I appreciate the way you worked with Mr. Dansky when he complained about his son’s treatment. Your listening and compassion were exactly what he needed and you turned a detractor into a strong supporter of our organization.” Now Kirby knows what she did, how it was helpful, and why it is important, so she will be more likely to repeat the valued behavior and develop further skills in that area. Being specific is also helpful when you need to provide feedback on what the employee did not do well. Rather than telling an employee, “Your communication skills need improving,” the employee will be able to take more effective action to improve if you open a dialogue with your specific observation such as, “I noticed that when you talked to the housekeeping supervisor about the way rooms were being cleaned, she looked upset and sounded angry.” This lets the employee know exactly what problem you are addressing and opens the door to constructive conversation about what she could do to improve in that specific area. You may be able to help with further coaching and interaction with your employee to help her identify and practice more effective ways of expressing her concerns to others.

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Coaching for Performance and Development What is Coaching? As a manager, you will meet regularly with the people you supervise to help them when they have questions, ensure they are progressing and performing as required, and to coach them for their growth and development. Some of the time you spend with them will involve reviewing their progress and accomplishments in their job responsibilities, often by looking at numerical measures (often referred to as “metrics”) in key performance indicators (KPIs) and helping them determine what and how to improve. This includes data and reports on their productive time providing direct care to patients, adverse incidents and errors, patient satisfaction, results of internal and external reviews of their documentation, patient outcomes, length of stay and time to discharge, and so forth. Be sure the standards and targets are clearly quantified as much as possible to ensure you and your supervisees agree to performance goals and expectations. Such regular and objective work together is important for keeping people motivated, developing as needed, and avoiding unpleasant performance problems later on. Coaching also involves helping your employee develop skills and manage behaviors that can help her advance or get in the way if she needs to adjust them. Behaviors requiring change could involve things like absenteeism, lateness arriving for work or meetings, or interrupting others. Behaviors that can be helpful for the employee to develop include things like volunteering to help out when needed, taking initiative to start projects, developing confidence in communicating and doing presentations, and speaking up in meetings. Skills could be technical skills such as working with software, data analytics, writing, and other knowledge-based work that a coach probably would not teach the employee directly but would help the employee find and access appropriate resources for learning, and then follow up to check her progress. Why Is It Important? Billy Carestio learned from the great leaders who mentored him that developing people involves translating and coaching, not just demonstrating



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what to do. “Know where folks’ comfort levels are and where their Achilles heels are,” he advises, to help people find their way. Now as Director of Nursing at Mental Health Partners, his focus is, “How to get people to bring their A-game every day,” as he facilitates his team members in delivering their best work.40 Ideally, coaching fosters employees’ development and commitment to the organization by helping them articulate and achieve their dreams. Everyone gets into his line of work for his own reasons. Author Daniel Pink (2009) provides insights on people’s motivation that can help you understand what drives your employees. What they want is: • autonomy, the drive to be self-directed; • mastery, the desire to keep improving at something important to us; • purpose, the sense that what we do produces something transcendent or meaningful and beyond ourselves. Of course, compensation is important, but it is not all that matters in retaining your people and keeping them feeling satisfied with work. Pink explains that after people are paid enough to take the issue of money off the table, they are not thinking about money and they are thinking about work; then the three things above have been shown through scientific research to lead to better performance.41 How to Coach The ideal approach to coaching your employees helps them understand the things they must do to fulfill organizational requirements, meet their metrics tied to their targeted goals and performance levels, and fulfill other expectations for their behavior. You could organize your approach to align with the motivational factors identified by Pink, as described in Table 2.5. Coaching offers the opportunity to ask your employees what they aspire to achieve and attain, and to help them prepare and develop the skills to succeed in increasingly responsible positions. Effective coaching is not just about providing answers but involves asking questions to empower employees to discover answers and commit to actions to attain what they identify.

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Table 2.5  Coaching with motivational factors What employees want

How to coach them to attain it

Autonomy: the drive to be self-directed

• Review with them the things they must do to fulfill organizational requirements and meet their metrics tied to their targeted goals and performance levels. • Empower them to take initiative.

Mastery: the desire to keep improving at something important to us

• Help them get better and better at the meaningful work they do. • Offer feedback, opportunities to practice, and work assignments to increase proficiency.

Purpose: the sense that what we do produces something transcendent or meaningful and beyond ourselves.

• Stretch them toward meaningful purpose. • Ask what they value. • Talk with them to explore how their work aligns with their values.

Your Role As Coach The coaching role you play is vital because your constructive guidance, feedback, and recommendations help your team members develop, stretch, and increase their abilities and effectiveness. “Clinicians are helpers,” Jen Leosz, LCSW, explains. “Supervising isn’t just about giving ­answers—empower the person you supervise to come up with answers.” For example, an organization may value high productivity and expect clinicians to see as many clients as possible. It takes initiative to fill a schedule. As a manager, you must show people how to do things in new ways and allow them to experience it. Give them choices on how they accomplish it, with room to try new things.42 Tina Howard, LICSW, recommends helping supervisees shift their perspective from micro to macro and vice versa. If they are looking at many things or too big a picture, help them focus on one strategy they can actually take and apply. Other times, reframe and help them broaden the possibilities. For example, in a school counseling situation, a therapist might be focusing on a student’s autism but maybe that is not the only or even key issue. Help them see other possibilities.43 When to Coach David Bachrach, MBA, FACMPE/LFACHE, a consultant who provides coaching to department chairpersons in academic medical centers, has



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been called in to address a problem described as, “We have a chair who’s failing.” Unfortunately, there’s a stigma associated with coaching after the failure is evident. He turned it around to building a foundation for people to succeed by building coaching into their onboarding plans rather than requiring rescue after failure, so now in the centers he consults with, leadership coaching is part of the package when someone is offered the position.44 You, too, can be proactive in building a foundation for success with the people who report to you. You should schedule regular time with all your employees for ongoing coaching. This is where you talk about their goals, progress, and performance. If you have recent feedback that you have not had a chance to share with them, you can do it during these meetings. This is when you review the metrics relevant to their position and how they are doing. If they need something to help them be more successful—such as tools, training, support from you, or your guidance— you may provide that. A lot of your time in coaching should be spent in listening to your employees, asking them questions, talking about what they need to do to succeed and considering how you can help them. Coaching and Supporting Your People Sometimes you will also support your people by advocating for them to rise to expanded responsibilities, or by advising them and supporting them in moving to an alternate track that positions them for long-term growth in alignment with their goals and values. In Volume II, Chapter 2, we will look more closely at how an organization created a workplace culture that helps employees realize their dreams and potential, and how to measure and leverage the strengths of the people on your team. In the next section, we will look at an example provided in an interview about a manager’s early experience in her new position managing a longer-term employee. Coaching for Employee Development: An Example A situation was described in one of our interviews by a high-level manager we will call Sandra whose early interaction with an employee, ­Terrence, revealed his dissatisfaction with his administratively oriented job as director of training. His disappointment was accentuated by Sandra being hired from the outside to fill the new position above him, which he interpreted

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as he being stalled in place instead of advancing to the next level. Sandra met weekly with Terrence and developed understanding of his interests and abilities, which included the clinical training and preparation he had completed and worked in before being promoted into his current job. Sandra asked Terrence what he needed and how he would like Sandra’s help in reaching his goals. As Sandra gained more perspective and awareness of the dynamics that supported growth and success in the new organization she was working in, she shared her observations with Terrence to get his honest impressions and build a collaborative relationship focused on his progress toward what he wanted. Sandra believed that Terence’s current administrative position would not lead him to the greater responsibility he wanted for working directly with the organization’s clients, so she recommended that he pursue a more clinically focused position that was opening up. Terrence expressed doubts and fears about Sandra’s suggestion because he viewed the alternative position as a step down, and away from the ­expanded level of responsibility he sought. Sandra, his manager, reassured him that she would support him through the transition and advocate for his continued growth and advancement. With this assurance from Sandra and Terrence’s growing trust in her genuine commitment to helping him achieve his goals, he made the move. As Sandra had promised, she helped Terrence by approving his enrollment in more training in the clinical leadership skills he yearned to develop and apply. Before long, with Sandra’s help and support, Terrence was ready and positioned to advance into a higher-level clinical role that he had dreamed of. By this time, the two had developed a mutually trusting and supportive working relationship. Terrence admitted to Sandra that he had initially felt fear and a lack of trust when she arrived at the organization as his new boss. Now he trusted Sandra and thanked her for helping him to succeed. Sandra’s pleasure with Terrence’s success and the transformation of their relationship was apparent as she shared this success story. Having experienced first-hand the benefits of supportive coaching from his own manager, Terrence in turn was following Sandra’s example to actively develop his own team members. He was involving them in more decision making about their development and their contributions to the



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organization’s mission serving its clients and promoting sound financial health for the organization.

Performance Tracking and Planning Since health care attracts people who want to help others lead healthier lives, who embrace challenges in difficult subject matter and handling life-or-death responsibilities, and who take pride in doing things well to earn the credentials required in their professions, well-designed coaching can be immensely valuable. By allocating time consistently to do coaching regularly with all the employees who report to you directly, you foster their growth and development and you will prevent many performance problems. This makes annual performance reviews, in accordance with the requirements of your organization, much more positive experiences for you and the people who report to you. Ongoing Conversations on Progress and Performance You should be reviewing regularly with your employees their goals and progress in meeting them along with their ongoing performance in meeting requirements such as productivity standards or targeted treatment outcome measures. This is part of your ongoing coaching and development meetings, with at least monthly frequency.

Keep Track of Accomplishments and Deficiencies You should also document performance deficiencies as well as accomplishments, for follow-up development and to build the content for annual reviews. Having a record of accomplishments may help you reward your employees who have performed well. If your organization requires ratings of performance during an annual review, there should be no surprises to any employee who receives low ratings from you. Because you have been having conversations all along the way about your expectations along with your feedback on the employee’s performance and any concerns you have, the employee would be aware of any problems he needs to

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correct and would have the opportunity to work with you on that before they become more serious. Reaching for the Future Just as you discussed with your employees the performance expectations of their current positions and help them assess and measure their progress and success relative to those requirements, you can have similar conversations about their goals for the future and what they need to work on to move toward them. At the Mental Health Center of Denver, we used the Catalytic Coaching approach, developed by Garold Markle (2000).45 We asked employees what they wanted to accomplish and what they aspired to do, which often revealed dreams and professional goals we could help them attain. That’s how a number of people moved into their first positions as managers, sometimes outside their current departments, and with the support and encouragement of the managers they reported to!

Performance Problems: What To Do? Now suppose that you have established a rhythm for working with your employees. You have gotten into the habit of providing timely feedback, set up meetings with them to provide further feedback and coaching, and you have made work assignments and delegated some tasks from your set of work to theirs. You have asked questions, been clear in setting direction, and clearly defined—via “word pictures” you have constructed with your employees’ participation—what good performance looks like and when things are due. Congratulations on setting the stage so everything goes smoothly and each of your employees performs at high levels that meet and exceed your expectations! But what if everything does not go as you expect? Suppose you see problems, communicate your concerns to an employee, and agree to what needs to change, but the problem persists and there is no improvement? It is a good idea to consult with your human resources department and review the laws in your state and rules in your organization. For the most part in the United States, employment is at will, which means an employee can be fired at any time for a good reason, a bad reason,



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or no reason, provided the reason is not illegal.46 This means that you can terminate a person’s employment and you do not necessarily need a performance-related reason, but you cannot terminate someone for an illegal reason, such as discriminating against employees based on their membership in groups related to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, or genetic information.47 So, even if, technically, an employer does have the right to terminate employees, employees may (and often do) file lawsuits against employers, often with the claim that the unwarranted action was based on illegal discrimination against the employee. And if your employees belong to a labor union, there may be specific actions spelled out in the labor agreement contract. Start with a Conversation According to Jeff Tucker, JD, VP of Human Resources at the Mental Health Center of Denver, when you have concerns about the performance or problem behaviors of any of your employees, first talk to that person, and then you must document your conversation. This is important in case the problem persists and you need to take further steps. Be sure that an outside observer would be able to understand what had transpired between the supervisor and employee. Later, if you decide to take disciplinary action that could lead to terminating the employee, you need solid evidence that you talked to the employee about the specific issue(s) that led to your action. Follow Up in Writing Jeff recommends a written follow-up message, usually in an e-mail if that is what your organization uses to communicate in writing, that documents the conversation and clarifies the intent. He recommends you frame it as a description of your conversation rather than in detached third-person language.48 At this stage, you are just acknowledging what you noticed and documenting your conversation in writing so the employee understands that you view it as important. For example, to document an initial

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conversation before it becomes more structured disciplinary action, it is better to write your message in terms of “You and I talked about . . .” rather than sending the employee a notice written in formal third-person language such as: “Medical Director Morgan Miranda spoke with Doctor Ryan Milton about Doctor Milton’s practice of . . .” Suppose, for example, you have an employee who tried to schedule paid time off for a last-minute vacation, and your other team members complained to you after the employee asked them to cover for her. So, you have a conversation with the employee to make sure she understands the required lead time and how coverage is arranged for such requests, and then you send her an e-mail. To clarify your intent to address concerns about paid time off, you could start by writing, “Ryan, I get a lot of questions about paid time off and how it works.” Then, you continue with what you discussed. “As we talked about today, our team follows the practice of planning ahead of time for vacation requests. Requests should be submitted at least two weeks ahead of time to Eli, who handles our schedule changes and balances requests for coverage so they are distributed fairly. I’m glad we discussed this today to make sure you understand the process and how it supports smooth coverage for our team members and patients. Thank you for your cooperation. Sincerely, Morgan.” The Specific Problematic Behavior This shows that you did communicate your policy and what you expect the employee to do. It leaves the employee with a clear reference to be prepared to handle the issue correctly in the future and provides you with solid documentation in case you need to refer to it for future follow-up if the same problem persists. Keep in mind Jeff’s advice to clearly show that you talked to the employee about the specific issue that was problematic. For example, it is not a good idea for you to suddenly fire an employee for being late to work if you never communicated your concern specifically about the lateness in



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arriving at work. It is not close enough if you did warn the person only that there would be consequences if she continued to be late in her documentation of treatment and services, and then she shows up late one day, so you fire her for being tardy because you feel like you have had enough of her bad behavior. Plan for Improvements and Its Measurements Or you might have an employee with poor performance not related to policy violations or undesirable habits, but he is not producing at the expected levels of proficiency or results. Start with the same approach, have a conversation. Compare his actual performance with the expected level, using objective data if available, such as reports of productivity, patient satisfaction, timeliness of documentation, scores on quality reviews. Ask for his commitment to improve and his ideas on how he will do it. Develop a plan with him with timelines and dates for when he will complete the needed changes and how results will be measured. Now you have your objective guidelines to encourage progress and monitor it. Evaluate Progress As you review your employee’s progress with him, you as the manager have the responsibility to determine whether satisfactory progress is being made and to communicate your assessment to him so he knows where he stands. At this point, you have communicated your concerns to your employee so he is aware of the problem and has reasonable opportunity to correct problems you have now made him aware of. And you have established the basis for continuing to develop a formal written warning and a corrective action plan if he does not improve as required. Progressive Discipline If you determine that the problem persists and will require further action, you are moving toward what is known as progressive discipline, in which increasingly serious consequences may be warranted. According to

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Mader-Clark and Guerin (2016), “Most large companies use some form of progressive discipline . . . . Whether they are called positive discipline programs, performance improvement plans, corrective action procedures, or something else, these systems are similar at their core, .  .  . based on the same principles: that the company’s disciplinary response should be appropriate and proportionate to the employee’s conduct.”49 You need to work with your human resources department to follow their guidelines and organizational requirements for determining consequences, such as putting the employee on probationary status or suspending some privileges, and timelines which may be leading to termination if improvement goals are not met. Immediate Action to Suspend or Terminate an Employee Because of the serious responsibilities in health care to protect patients from harm and potential life-and-death consequences, some employee actions could be serious enough that you will need to bypass the initial conversation and progressive discipline to proceed to immediate action to remove an employee from the workplace. This may be necessary to protect the organization, patients, other employees, or the public from harm. Such employee actions could involve illegal and unsafe practices such as substandard care practices that put patients in danger of serious health consequences, illegal dispensing of drugs, theft or improper handling of controlled substances, harassment and other misconduct toward patients or other staff, fraudulent activities, and others as specifically identified in your organization’s policies or employee handbook. Serious misconduct could warrant immediate termination of the employee or suspension from work, with or without pay depending on the alleged actions, while an investigation is conducted. You might need to notify licensing boards for violations of professional ethics or practice standards, or even law enforcement for illegal activities or threats to safety. It is essential that you involve your human resources department. They have expertise in the specific steps to follow to investigate possible misconduct, and they know who else to contact such as your organization’s insurance carriers for malpractice and other liability.



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Meeting the Challenge Remember that while performance problems can be challenging, now that you know about the processes for handling them, you can be more confident and feel prepared and professional if the time comes when you do need to address them. You will not be dealing with them alone if they turn serious. Stay in close touch with your human resources department and your boss for guidance and support. My colleague, Roy Starks, MA, VP of Rehabilitation Services and Reaching Recovery at the Mental Health Center of Denver, successfully motivated his teams to achieve high levels of performance by focusing them on meaningful outcomes for the consumers they worked with. Nevertheless, in his long career as a manager, he recognized that despite what you do as a manager, some people do not perform as well as needed. His advice to new managers is, “Don’t take it personally.”50 When Dixie Casford remarked, “Terminations should never be easy,” she recognized that they might be necessary but should not be something we enjoy.51 It is easier to set expectations ahead of time. Another manager, who needed to develop a corrective action plan with an employee who was making insufficient progress, reported that the specificity of plans and goals with monitoring was helpful. After working together through the process, the employee told this manager he was her strongest ally.

Chapter Summary and Key Points In this chapter, we looked at what health care managers do, showed you how to delegate, and looked at the power you have and trust you need to build in your new managerial role. We drew upon some resources such as books that help managers in any industry handle their new leadership responsibilities, and showed you some representative scenarios that illustrate what you can expect in a health care setting. We emphasized the importance of setting clear expectations for behavior and performance, showed you how to hold people accountable, and looked at how to coach your employees for their performance and development. We considered performance problems and advised you on how to handle them. Now you are in charge and ready to manage your team successfully!

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Key Points: 1. Ensure that your people have the tools, resources, and support needed to succeed in their jobs. 2. Recognize your power and use it effectively to make decisions and treat people fairly. 3. Build trust with your team members by supporting their success. 4. Confront resistance promptly with honest conversation. 5. Do not tolerate disrespect and insubordination. 6. Delegation frees up your time and helps develop others. 7. Delegate with clear expectations and support your employees’ success. 8. Involve people in decisions about how they accomplish goals. 9. Explain what you expect and hold people accountable. 10. Expectations apply to behavior toward you and others as well as performance that can be measured numerically. 11. Meet regularly with the people who report to you for supervision and coaching. 12. Involve your human resources team for performance problems that require discipline or termination. In the next chapter, we look at some specific approaches to help you plan and organize your activities. After that, we will expand your perspective to help you manage not just down, but up with your boss and sideways with peers and others to be an effective health care manager in multiple directions. Now, you are ready to start practicing what you have seen with the following activities. Are you ready to work with the people who report to you, clarify and communicate expectations, and find the guidance and support you need? It is time for you to take charge!

Learning Activities for This Chapter 1. Identify the factors that helped you advance to where you are now. How will your skills, experience, and other resources help you succeed in your new role? Discuss these with a partner or group and make notes on their feedback to refer to when you need to boost your confidence in your managerial capabilities.



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2. Consider the topics of fairness and friendship that we discussed in this chapter. a. What expectations and requests do you anticipate from people you will be supervising who are your former teammates and those you have had personal friendships with? How will you respond and ensure that you are treating your team members fairly? b. Does fairness require that everyone be treated exactly the same in all situations, or are there valid reasons to adjust rules, rewards, or working conditions in different ways for different team members? c. Talk to an experienced manager, mentor, or buddy to find out what requests they have received and adjustments they have made. Explore with them how it worked out for those who were involved. What practices would you adopt or do differently? 3. What things have you been handling yourself that you could delegate to others, particularly those whom you supervise, to free up some of your time and foster their growth and development? Refer to the guidelines and example in the section, “How to delegate.” a. What conversations will you have to make sure they know what is expected for handling and completing these activities? b. How will you follow up to make sure your supervisees have what they need and these delegated activities are on track for completion as required? 4. How will you communicate with your team to emphasize the value of patient safety and provider accountability? Are there any specific problems or issues in your workplace that you could improve with your team to ensure that people feel safe and free from blame if they openly admit to problems and mistakes? 5. Identify an area of performance or behavior that you would like your team to improve in. a. Develop a Performance Scale to paint clear word pictures of the differences between bad, good, and great performance as shown in Table 2.6. Include at least three examples in each column. b. Consider how you could work with individual employees to engage them in developing the scales for their specific activities—or, identify an area where you want to do better and fill this in to improve your own performance!

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Table 2.6  Exercise on word pictures for bad, good, and great performance

Behavior or performance area to improve: ___________________ Bad performance

Good (expected)

Great

• Word picture example 1: • Word picture example 2: • Word picture example 3:

• Word picture example 1: • Word picture example 2: • Word picture example 3:

• Word picture example 1: • Word picture example 2: • Word picture example 3:

6. Refer to the section, “Expectations for you and your team” and the examples in Table 2.1 of a brief, simplified set of requirements with representative items for illustration. Fill in Table 2.7 to identify the most important requirements and standards or target values that your team is responsible for delivering. Are there other columns or information used in your organization or that you would add to keep your team on track? Table 2.7  Exercise on expectations for you and your team Requirement

Required by

Target

Performance (most recent quarter)

7. Review the Expectation Management Model that was introduced in this chapter and illustrated in Figure 2.1 with complete descriptions of relational elements. Figure 2.2 is provided below for a brief reminder of the diagram, without the full relational equations. Pick one area of performance or behavior that you have been working on to improve in your team or in your own performance.



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Figure 2.2  Expectation Management Model, Abbreviated Diagram

a. Identify the objective or area you have focused on. b. What is the desired result, as a numeric level of performance or clear description? c. What is the current level of performance, in numeric or clear, descriptive terms? d. As you evaluate actual performance relative to desired target performance, what needs to be adjusted or recalibrated? Consider: i. Is this a useful activity or objective to focus on to add value to the organization? ii. Are your expectations for the desired result reasonable and appropriate? iii. What adjustments to behavior and activities are needed to achieve an appropriate target level of performance?

CHAPTER 3

Planning and Organizing Chapter Overview 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

Planning and Being Proactive There are many activities and priorities competing for your attention as a new manager. Levinson and Cooper (2015) acknowledge that your intentions are important in setting the right direction, and learning to follow through turns your good intentions into action.1 Developing a 30/60/90-day plan can help you get organized and track your progress along the way as you learn how to operate in your new role

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and determine how you fit into your organization.2 Such plans were initially targeted to employees starting a new job in a new organization, and can also help you if you have moved into a new role with new management responsibilities in the same organization. Guidelines for Your First 30/60/90 Days • Your first 30 days: Initially, you will be in a learning phase. You will observe and listen to understand how things are done and what needs to be done. You will find out your boss’s expectations of you, begin to develop working relationships with coworkers, get to know the people who report to you and start meeting with them, and gain understanding of the culture of the organization and of the team you are managing. • From your 30th to 60th day, having listened and learned, you are ready to contribute more to the conversation. Start applying your unique skills and strengths where they can be useful, develop versatility by taking on some additional things, and continue to be aware and focused on your boss’s expectations of you. • From your 60th to 90th day, you should feel more confident in your role, ready to be more proactive and involved in a broader set of activities such as key change projects, work groups focused on solving specific problems, and committees. Example: My First 90 Days as a Health Care Manager Here is how using 30/60/90 days planning like this helped me when I transitioned from the role of therapist on a community treatment team at a remote site into my new position as director of quality improvement at our central administrative office. • First 30 days: I arrived in my new role with a mission to develop tools and solutions to help clinicians provide high-quality care and services to our clients and patients. To develop a foundation to accomplish this, I organized a “Clinical Site Needs Analysis”3 in my first 30 days.



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My new boss, the medical director, was particularly supportive because he had asked during my interview what I would do to get started on the job and I had responded with a brief description of how I would conduct this needs analysis. I started by finding out where all the clinical teams were located, who led them, and when they had their team meetings. I developed a questionnaire, with input from my peer-level directors, to ask each team about their goals and activities and what my quality improvement team could do to help them do their best work. In short, I developed a plan, asked a lot of questions, and enlisted the support of my peers (the clinical directors), my boss, and my team members for this project. • 30th to 60th day: In the next phase, I contacted the manager of each team to introduce myself in my new role, explain what I wanted to accomplish, and ask if I could visit one of their team meetings to interview the team. Each manager welcomed me to visit, so I scheduled a visit at each of our 52 teams and completed an interview with all of them. In the meantime, I listened and participated in meetings with the other directors to understand organizational priorities, and presented brief updates on my progress in scheduling and conducting the needs analysis. • 60th to 90th day: In this phase, I completed the interviews with each team, and collected the needs they had expressed into 12 areas I could organize into projects that my quality improvement team and I could implement to deliver help and support to clinical teams. This set the stage for launching some major change projects through work groups and committees to deliver helpful tools and processes to remove barriers and enhance workflow. One was a system of electronic templates we developed and disseminated that alleviated the repeatedly mentioned problem of too much manual paperwork for treatment planning and other documentation. (This was before we had the electronic medical record systems now required and adopted by most health care organizations.) • Results: Thus, by my 90th day in my new role, I had developed mutually supportive working relationships with my peers and their

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clinical teams, introduced some new operational approaches that I had learned from my prior work in the computer software industry and adapted them to work in our health care organization, established some new cross-functional work groups involving various clinical and administrative representatives, enlisted the participation and commitment of my initial small quality improvement team, attracted some others to join our team, and delivered solutions to 12 problem areas identified in the team interviews. This momentum positioned us to become involved with other key organizational initiatives and projects, which established the value of our growing quality team in supporting our overall organizational mission to help our clients recover and lead more satisfying lives. Being Proactive with Each New Position Remember to plan proactively for each new position and role you move into, especially in a new organization where other people have not seen firsthand what you have accomplished previously. I realized awhile after I had moved to a new position in a different organization that it was not enough to jump into replicating approaches that had succeeded in one organization; the culture and expectations were different in the new organization. Even though I felt clear about my intentions to meet every team in my new organization because I had experienced the benefits of establishing relationships organization-wide, I still needed to step back and formulate this into a tangible plan that I could use to show others what I was doing and why it was important. In retrospect, I see that my new boss needed to see well-formulated written plans to show her where I was headed, explain the rationale for my approaches, engage her in ensuring alignment with big-picture organizational strategies, and instill confidence that I had a vision and knew how to execute it. When I bypassed the fundamental steps of writing and presenting my plans to my boss and colleagues, I missed the opportunity to get their buy-in early on and to benefit from their wisdom and experience with the culture and processes in the organization that I was just becoming acquainted with. This would have saved time and energy later and improved results.



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It can be challenging to resist the urge to jump in and take immediate action toward pressing goals and priorities before understanding the environment where you are operating. Take a deep breath, look at the full scope of what you are expected to do, identify the strengths and experience you bring with you, and take the time to do some solid planning and communicating to build alliances and support for you and your plans. Apply fortitude and discipline to allocate focused time alone for thinking things through. As you channel your ideas and intentions into written frameworks for planning, consider how to utilize meetings, decision-making processes, expectation management, and time management. Such activities help you build solid plans and follow through to successful results. We explore these topics further as we progress through this chapter.

Organizing and Leading Meetings An opportunity for new managers to establish their leadership positions with their teams and other departments is through meetings that are purposeful and effective in accomplishing goals. If you have participated in effective meetings that accomplished their goals and helped move the team and organization forward, consider what worked well that you could apply to the meetings you will lead. A common lament is that there are too many meetings, they consume too much time, and they are not productive, as illustrated in Patrick Lencioni’s popular business book, Death by Meeting: A Leadership Fable, “centered around a cure for the most painful yet underestimated problem of modern business: bad meetings.”4 Meetings incur considerable time and expense because of the multiple people involved and the time they divert from other activities, such as direct patient care. Thus, we provide some guidance here from observations in health care organizations. There are different meetings for varying purposes. In most organizations, there is an expectation that managers meet on a regular schedule with their teams of direct reports all together and individually with each of the people who report to them directly. It is important to establish a consistent day and time for regular meetings to support a rhythm, help people prepare as needed, and schedule the rest of their working

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time. Of  course, there will be times when you will need to be flexible and be willing to cancel or reschedule established meetings to accommodate other events and activities such as companywide meetings, external meetings you or your staff are required to attend, company holidays, and others. You may be in charge of various meetings with different purposes and participants. In some cases, you may choose to delegate the running of a meeting to other team members when it makes sense for the roles they are in. For example, project managers can be very effective in reviewing schedules and tasks for the specific projects they have been assigned to lead. A weekly administrative team meeting may have a duration of one or more hours, depending on the level of organizational responsibility for setting policy and strategy, which tends to require longer meetings of 2 or 3 hours. There may be shorter clinical weekly team meetings focused on specific patients or clients and their needs. Daily morning huddles are another type of meeting with clinical leaders and staff, much shorter in duration and designed for prompt feedback on processes such as operating room set up and patient flow. Cloud (2010) described the benefits he had seen of daily, 15-minute morning meetings designed to “cast vision, give information, share stories of success, and infuse strategy, thus giving a daily dose of energy that kept it all moving.” These short meetings kept the team aligned around goals, caught problems early, shared lessons, and acknowledged problems. These short meetings did not require preparation so they did not distract from other work; rather, they energized it and kept things moving.5 Working meetings may be focused on particular projects, tasks, and decisions. Work groups and task forces tend to be time-limited groups that are formed to solve specified problems or to complete defined projects. To sustain momentum of carrying out projects, they tend to meet every week or every other week, for an hour or two, depending on availability of members. Some meetings are nonrecurring. They are called to discuss and make decisions about specific current issues. These might require only one, or a few, meetings to resolve the issue or to complete timely solutions to problems. Table 3.1 provides a summary of various types of meetings.



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Table 3.1  Summary of meeting types Meeting type Purpose

Frequency

Duration

Individual

Supervision and coaching with each person who reports to you directly

Usually once a week, could be less frequent with more senior and experienced staff

Typically an hour. May be shorter duration and more frequent

Administrative team meeting

Planning and followup on overall team operations and goals, organizational requirements and procedures

Weekly

Typically 1–2 hours

Clinical team meeting

Review and resolve specific patient issues, plan treatment, and review progress

Weekly or more frequently

Up to an hour

Morning huddles Review with clinical leaders and team members the prior day’s activities. Provide prompt feedback to adjust and plan for the coming day

Daily

Typically about 15–20 minutes, up to a half-hour

Working meetings for time-limited projects and tasks

It is desirable to meet weekly or every 2 weeks to maintain work momentum. Actual scheduling depends on availability of participants. Larger groups spread widely across locations may meet less frequently, typically once a month.

1–3 hours, depending on frequency and amount of work to be completed in each meeting

Usually these are one-time occurrences to reach a timely decision. Occasionally a follow-up meeting may be needed to allow for further research on the issue or consultation with others not present.

Usually 1 hour, depending on the complexity of the issue. More complex or high-impact decisions might require more time for needed evaluation of alternatives.

Members of workgroups or task forces meet to decide on policy or organizational processes, develop work schedules and products, plan and disseminate communications about decisions and implementation to others in the organization

Nonrecurring to Discuss and reach an address special immediate decision on a issues and current problem or issue pressing problems

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Meeting Purpose Be sure to clearly establish and communicate the purpose and structure of each type of meeting you are responsible for leading, and be aware of other surrounding and related meetings. This sets expectations for meeting members’ behavior with regard to what issues and topics should be handled where and facilitates coordination of problem-­ solving and communication. For administrative and strategic meetings, as well as meetings of time-limited work groups convened to solve specific problems, you should plan and distribute an agenda ahead of time; this allows meeting participants to prepare adequately for topics they are responsible for and serves as a plan for allocation of time during the meeting. This planning can help you prioritize issues and avoid trying to squeeze in too many topics without adequate time to consider and resolve them. Formal, written agendas could be eliminated for short, focused meetings such as clinical huddles, which follow a daily course of a routine health care process that becomes familiar to participants—such as review of prior day’s work in the operating room, successes and recognition for good work, problems and plans for improvement. Ideally, some form of data feedback is incorporated into these meetings to help team members know what they should work on and if their improvement efforts are effective in implementing the right changes.6 For administrative and strategic meetings, you will want to work with an administrative assistant or other team support person if available to you. This is an opportunity to work with that person to enlist his or her help and support, work out schedules and approaches that you are comfortable with, and delegate ongoing details and maintenance of agendas and meeting follow-up to ensure your meetings are effective in accomplishing your team’s goals and work. There are other roles that can be rotated among meeting members; an important one is timekeeper to keep track of time usage and remind people when the discussion needs to be wrapped up, tabled, or delegated to another team or committee meeting.



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Meeting Structure Effective meetings, such as a weekly administrative or working team meeting, are organized with a structure something like this: 1. Roles and responsibilities Roles should be clearly in place with each responsible person aware of what they are assigned to do to support the meeting. Roles and responsibilities include: Facilitator: As the manager, you should facilitate your team’s meeting, at least initially while you are establishing your new leadership responsibilities. Note-taker (also referred to as the Recorder): Be sure to have a note-taker to record decisions and action items for later reference and follow-up. To ensure consistency in recording and follow-up, it is best for the note-taker to be in an established role such as an administrative assistant or team support person if you have one. Timekeeper: It can be helpful to have a timekeeper to help the facilitator focus on meeting content and dynamics. This helps ensure you start and end each meeting on time and cover the agenda. The timekeeper responsibility usually rotates among team members, but be aware that some are better at this than others! Ultimately, you are responsible for starting and ending the meeting on time (or early!), so assign timekeepers appropriately. Participants and your interaction with them: As the meeting leader, it is also your responsibility to ensure that participants have the opportunity to contribute their ideas. Some members will tend to talk more than others, and some may hold back on contributing. You may need to gently prompt by asking, “Does anyone else have something you’d like to say about this topic?” Be aware of how people are reacting; their body language might suggest some thoughts and feelings they are not expressing in words. At times, you will need to address some participants directly to draw them out, explore concerns, and ensure the team gets the benefit of particular knowledge or experience relevant to the issue at

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hand. For example, “Kris, it looks like you have some concerns about the approach we’re planning to take with scheduling nurse coverage. Do you foresee a problem we should be aware of?” or, “Robin, you’ve implemented accounting systems like this for a long time. How do you think clinical staff will react to the new online expense-reporting requirements?” or, “Dani, you mentioned earlier that you have some thoughts about how we could handle unusually high numbers of patients who could show up some days in the new walk-in clinic. Do we need to put that on the agenda for that planning group?” To ensure discussion time gets allocated adequately for those who need to contribute but have not, and to avoid having the naturally talkative members dominate the discussion or decisions, you may need to thank those members for the contributions they have already made and gently emphasize that you would like input from those who have not spoken yet. For example, “We’ve heard a lot of good ideas from different perspectives of many of you. I’m interested in hearing ideas and reactions from others who might still be thinking about these and haven’t had a chance to share your thoughts with us yet.” 2. Introduction and focal point This could be a reminder of the meeting purpose, organizational mission, vision, and values, and other guiding principles to align the team. If there are new members or visitors, be sure to do quick introductions to ensure every participant knows each other’s name and role. On one executive team I belonged to, we had recently redeveloped our organizational values and wanted to reinforce our active adoption of them. So, we periodically checked in on one of our company values. Leadership of this section of the meeting rotated and was assigned in the prior week’s meeting. The rotating leader of this section selected a value and briefly talked about an example that illustrated the value at work in the organization. For example, many organizations include “teamwork” as a value, so the leader might provide a 1-minute example of how several people in different departments worked together to ensure a patient’s medications were refilled seamlessly after an unexpected hospital discharge just before a holiday. Then two or three other team members could respond with other examples they had seen in action. This part



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of the meeting reinforced our alignment of operating values of the organization, in this case working as a team to serve our patients. And the rotating responsibility for this section kept this team’s members engaged and practicing their own leadership skills, which often reminded them to recognize the great work of the teams and people reporting to them with feedback directly to them in their later interactions or meetings. For example, “Suresh, during the clinical directors meeting yesterday, Fran and Kim made a point of recognizing how you and your team went out of your way to respond quickly and coordinate everything that needed to be done to keep everyone safe and informed during last week’s emergency in the waiting room. Thank you for all the training you’ve done to prepare your team members and instill in them the value of rapid responsiveness. Please let your team know their efforts were noticed and appreciated.” 3. A brief check-in or question A benefit of meetings is their capability to help build relationships and promote collaboration. Managed well, meetings can enhance efficiency through real-time collective problem-solving. For some meetings, this part could be an ice-breaker to help people get to know each other and build alignment. On one executive team I belonged to, this was a new question each week, posed by the CEO, who was the meeting facilitator. Sometimes he asked for suggested questions from team members. These often got us laughing and ready to collaborate and work together. (One of my colleagues shared brief metaphorical fables in which her household and neighborhood pets illustrated some of our organizational goals. These sparked our creativity to help us consider things in new ways for effective problem-solving later in the meeting.) A technique used by our CEO when meeting with groups of representatives from external organizations was to ask each participant, “What will make this a great meeting for you?”7 This clarified varying expectations and helped the facilitator guide the meeting to ensure success in the eyes of the participants. On another team, we each described briefly one thing going well, to set a positive tone for the meeting. On my own Quality Systems team, we shared some current or past experiences and learned some memorable and amusing things about each other that built our

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camaraderie, trust, and enjoyment working together to implement challenging projects. Choosing a question that highlights the importance of particular agenda items can amplify the value of the question. Thus, if the agenda includes working on patient experience and satisfaction, an opening question about examples of good customer service that we meeting participants had experienced ourselves can provide context that helps us appreciate the topic and facilitates renewed interest and creativity in problem solving. Caution! When you are planning your meeting, be aware of the time consumed per member on an opening question or activity. On a large team of a dozen or more people, this can consume a significant portion of your meeting time. For this to work, you will need to utilize the timekeeper to ensure no one takes more than a minute or two, that no one monopolizes the time with overly long stories and details, and that people learn to hold their dialogue and responses until later. This is an opportunity to apply Shari Harley’s (2013) suggestion to set expectations and agreement ahead of time8 to make it easier to keep people on track. For example, “These are great examples we’re hearing. And we’ve all agreed that we’ll spend no more than 10 minutes on the meeting opener, and we’d hold our follow-up questions and dialogue until after the meeting so that everyone can contribute something briefly before we get to the other things we need to cover on our agenda. Thank you, Jo, I’d like to hear more about your experience later. Let’s continue—Brett, you’re next.” This will take some practice. Balance fun with practicality and be prepared to repeat and adjust as needed! 4. Follow-up on action items from previous meeting(s) This was added as a standing agenda item of a team that had many urgent activities as a result of changes in health care funding. Having a systematic and predictable follow-up on the agenda proved to be very effective in ensuring that team members were aware of and followed through on the action items they needed to complete, usually from the prior week. Occasionally, items would carry through for a second week, but the norm was established to complete most things within the week to avoid backlogs of critical issues and ensure prompt implementation of solutions.



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5. Standing agenda items and updates These can be periodic or rotating report-outs from designated team members and functions to ensure communication and coordination. This can be particularly helpful if your team members work in different physical areas or functional responsibilities, to increase their awareness of what others on the team are doing, how members can support each other, or share resources and learn from each other. Major organizational projects, such as the implementation of a new electronic health record used by all clinical staff and most administrators, need regular visibility because of the high impact of the project with a strong need to respond quickly and remove any barriers that might threaten the project’s progress. 6. Other updates or problems Often this is what most of the meeting time is allocated to and where the hard work gets done. Typically, team members can request time on the agenda. You or an administrative organizer need to work with the requestor to determine the amount of time needed to discuss, the urgency and priority of the item, and to verify that this is the right meeting or forum where the item should be discussed. You need to apply judgment and discipline to slot these requested agenda items into the appropriate meeting and date depending on available time and urgency of resolution. 7. Meeting wrap-up This is an important final step to close the meeting and transition what was accomplished back into your team’s continuing work. If your meetings generate follow-up action items, it is crucial that there is a brief review of the items and responsible person for each one, so people leave knowing clearly the assignments and activities they are expected to do. Some meeting facilitators include a very quick round of feedback on the meeting; it could be a one-word description, a numeric rating, or something they liked about the meeting. This provides a gauge for the facilitator and team members about how they are working together and what could be improved, helping to instill shared responsibility in team members for the health and functioning of their team.

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Meeting Agenda Format Example Design a table with the topic areas you will cover and time allowances, as shown in Table 3.2. Include a column to record key decisions and Table 3.2  Meeting agenda format example Meeting

Clinical Training Workgroup, Wednesdays, 1:00–2:50 p.m., Garden Conference Room

Facilitator

Perry Reynolds, APRN, Training Director

Recorder

Dru Casper, Administrative Assistant

Members Present

Pan Arlen, DO, Physician; Dorian Greshen, LCSW, Clinical Program Manager; Carmen Hogan, RN, Manager of Nursing Services; Marni Lewis, MD, Clinical Director; Misha Martinez, DDS, Director of Dental Services; Mali Peznyk, MS, Clinical Training Coordinator

Members Absent

Ariel Pyle, MBA, Director of Human Resources

Guests

Tynan Sherman, APRN, Program Manager; Franklin Zimler, LAC, Clinic Supervisor

Topic

Key points

Meeting opener What’s one valuable thing you learned this week?

Decisions and action items

Topic owner

Start time

Perry Reynolds (meeting facilitator)

1:00 p.m.

Review of action items

1. CPR training status 2. Certification tracking system 3. Training calendar completion

Carmen Hogan, Mali Peznyk, Dru Casper

1:10 p.m.

Patient safety course

Training vendor proposal summaries

Tynan Sherman, Franklin Zimler

1:15 p.m.

Training priorities for next quarter

Group brainstorming and prioritization

Marni Lewis

1:45 p.m.

Dru Casper

2:30 p.m.

Perry Reynolds

2:40 p.m.

Review action items and owners Meeting feedback and wrap-up

What motivated you in today’s meeting?



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actions from the meetings. This will make it easy to keep track of what was decided and help the recorder complete and distribute notes quickly to ensure people promptly complete their follow-up action items. A blank meeting agenda form is included in Appendix B.

SBAR: A Tool for Effective Meetings and Other Decision Making A useful tool for preparing for some meeting agenda items, particularly for problem-solving and action proposals, is the “SBAR,” which provides structure and intentional planning to identify the “Situation, Background, Assessment, and Recommendation” in terms of: S = Situation: a concise statement of the problem B = Background: pertinent and brief information related to the situation A = Assessment: analysis and considerations of options—what you found out and how you evaluate alternative courses of action R = Recommendation: the actions you believe are the best solution and for which you request approval and support from others to move forward in carrying them out. Brief Example for Clinical Care The Institute for Healthcare Improvement (IHI) provides online tools and resources for using the SBAR approach. An example in IHI’s materials illustrates how a medical treatment team could structure its communication and approach in an ad hoc gathering of team members to respond immediately to a crucial medical emergency with a patient. In that case, Situation is the patient’s medical condition. Background provides the relevant factors in the patient’s medical history. Assessment is a brief clinical assessment with relevant diagnostic factors. Recommendation is the clinical response and treatment recommended by the clinical responder.9

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Expanded Application for Organizational Problem-Solving The SBAR approach can be adapted for use with other health care professionals and administrators. It is useful in nonemergency planning and problem-solving to improve processes and decision making throughout the organization. The tool was introduced to our health care organization by our CEO at Mental Health Partners, Kelly Phillips-Henry, PsyD, MBA, who had used it at another organization where she had worked. SBAR proved to be valuable to organize communication and preparation around problem-solving agenda items and action proposals that people requested for inclusion in meeting agendas. By providing structured discipline and intentionality in articulating the problem and developing recommended solutions prior to meetings, we used our meeting time more efficiently and it was easier for meeting participants to make timely, well-informed decisions. A brief illustration is presented in the next section. Another example, from an actual project I proposed and led to support service redesign, is provided in Appendix C. SBAR Example for a Prescription Refill Problem S = Situation: In the past month, patients have been running out of medications before their refills are processed and delivered. Several patients showed worsening of their symptoms while emergency medications were obtained and prepared for dispensing. B = Background: We have had organizational changes in our in-house pharmacy that resulted in sudden turnover. Experienced pharmacy staff set up alerts for the nursing team and assisted actively in supporting medication refills. A = Assessment: One option is to formally shift prescription tracking responsibilities to the nursing team. This requires additional training and ongoing manual tracking. An alternative is to implement automated tracking capability in the pharmacy module of our electronic health record system. Our technology team checked with our software vendor, who can provide this functionality for additional $10K per year, with initial training of nurse users for $2K.



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R = Recommendation: Invest in electronic software functionality immediately. Install the added software module and train nurses in groups as already scheduled for quarterly staff development starting in three weeks. Benefits of SBAR Our use of SBAR was broadened to be particularly helpful in structuring processes that supported but were not part of direct patient care activities; therefore, it was helpful in engaging nonclinical administrators in developing solutions that ultimately improved service to patients and clients (for example, collection of insurance co-payment fees and designing the patient experience in coming to an initial appointment). By preparing ahead of time and describing succinctly each element of the SBAR, the person bringing forth her recommendation helps others understand the problem and makes it easy for them to support her proposed solution. SBAR helps focus the discussion on solving the problem, which keeps the meeting on track and supports timely, efficient decision making.

How Decisions Are Made Many decisions are made at meetings but many are not. This section discusses the various ways decisions are made. As a manager, you are responsible for making some decisions, and for supporting other decisions that you did not make yourself or might not have had any involvement in making. It is important for you to find out the extent of your authority as soon as you start working in your management role so you will know the extent of your authority for decisions. Be confidently decisive while careful to avoid overstepping your bounds in taking on decisions that rightfully belong to others. Dialogue Is Not Decision Making As Patterson et  al. (2012) advise, you need to be aware that “dialogue is not decision making.” In other words, just talking about things with other people and seeming to agree on an approach or solution does not

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necessarily establish a decision that will be upheld and followed by others. Decisions are made by leaders and managers who have authority to do so, and they may be the ones to “decide how to decide.”10 Put Decisions into Effect Promptly As Peter Drucker (1967) stated, “The most time-consuming step in the process is not making the decision but putting it into effect. Unless a decision has degenerated into work, it is not a decision; it is at best a good intention.” Drucker recommended being systematic and careful to make effective decisions that get implemented well.11 Drucker explained that decisions are judgments that represent choices between alternatives based on what is known at the time. He recognized that decisions can generate disagreements.12 Disagreement and conflict are a normal part of life, and we will look more closely at how to handle them in Volume II, Chapter 1. Despite the potential to generate conflict, it is wise to make decisions promptly and avoid procrastination. Armstrong (2013) advises that we make decisions faster to free up time for other things, or at least get started on making difficult decisions and allow the momentum to carry through the decision-making process rather than to delay and avoid difficult decisions. Like Drucker, he advocates for being systematic and rigorous in problem-solving and thinking, considering other facts that might be relevant, and learning from your past experience, while recognizing that situations change. It is wise to talk it through to get other viewpoints, especially from those who are likely to disagree. Leave time to think it over, pausing even if only for a few minutes to “avoid knee-jerk reactions” and “to allow yourself time to think through the decision you propose to make. And confirm that it is logical and fully justified.” Consider the potential consequences and think about unintended consequences that could occur.13 Manage Expectations after Decisions After decisions are made, it is important that you know how to follow up to get required actions done. Patterson et al. (2012) recommend that you turn these crucial decision-making conversations into action and results.



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“Determine who does what by when. Make the deliverables crystal clear. Set a follow-up time. Record the commitments and then follow up. Finally hold people accountable for their promises.” By doing so, you increase the motivation and ability of people to deliver on their promises, and you also create a culture of integrity.14 When decisions are made, clarifying expectations helps ensure that the decisions are carried out effectively. The Expectation Management Model (which we introduced in Chapter 2 and show again in Figure 3.1) can be applied to move the decision from general discussion to specific implementation. The Evaluation and Calibration steps ensure there is a feedback loop to revisit whether activities were carried out as intended, and allow for renegotiation if adjustments are needed to objectives and the expected level of performance in achieving them.

Figure 3.1  Expectation Management Model

Managing Expectations through Evaluation and Calibration Here is an example of how an executive team communicated with its board of directors to manage expectations about the team’s performance in one of its established key performance indicators (KPIs). The particular KPI required that the organization increase the number of people served

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by the organization. Everyone supported the decision to include this KPI and agreed to the general principle, but the details about how performance in this area would be measured had not been specified. The organization counted the people it served by combining information from several different sources, including electronic records and separate manual counts on paper. This was necessary because the organization received special funding for several innovative programs that connected with people in need out in their community settings, which precluded the completion of full administrative enrollment in the organization’s electronic health record in an office setting. The organization also was extending its reach in the community through public education and consultation with teachers in classroom settings to support the health and well-being of multiple students in the classrooms. Such activities were tracked by clinicians with specific activity codes that were stored and retrievable in the electronic health record system. At the end of the measurement period, when counting methods used previously were applied to the latest period, it appeared that the number of people served had actually decreased, particularly with the expiration of one of the grants that had funded services in earlier periods to a specified number of people. However, the senior managers who were leading the innovative outreach and service delivery in the community knew that they were actually reaching more clients and community members. By presenting evidence of the high count of the additional services that actually touched many more lives than ever before, the executive team was able to renegotiate with its board, who agreed that the team was actually surpassing the expected performance in the intended focus of the KPI, which was to increasingly serve more people. Thus, as the result of reevaluating the counting methods relative to available funding and current service delivery practices, the team was able to renegotiate with its board of directors for recalibration of the measurement of its service volume performance, and achieved better visibility in its scorecard for the work it was doing. This supported the board in its decision to judge that the organization had achieved its expected level of performance. Note that in this example, the board had the authority to make command-level decisions, which will be explained below, without any



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input from those working in the organization. Fortunately for the executive team, the board was open to consultation for input about reasonable measurement approaches, which influenced its ultimate decision. We explain more about such different types of decisions in the next section. Apply the Right Decision Type at the Right Time Be aware that there are different kinds of decisions that are commonly used in organizations. Patterson et al. (2012) describe them as: • “Command: Decisions are made by those in authority without involving others. • Consult: Input is gathered from the group and then a subset decides. • Vote: An agreed-upon percentage swings the decision. • Consensus: Everyone comes to an agreement and then supports the final decision.”15 As a manager and leader, you might use all of these at different times. Armstrong (2013) reminds us, “One of the key skills a leader or manager needs is the ability to analyze and read situations and to establish order and clarity in situations of ambiguity. Leaders need to have a sense of purpose and the ability to influence others, interpret situations, negotiate and express their views, often in the face of opposition.”16 Command Decision Making Surely there are times when the top leaders in your organization face tough decisions and need to make command decisions without involving others. Command decisions are most appropriate in crisis situations or for other serious and urgent matters. If the building is on fire, there’s no time to talk with others and decide what to do—just get everyone out of the building! But the Chief Executive Officer of your hospital might also need to make important decisions about the hospital’s future when faced with major changes such as mergers with other health care organizations, or

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during major overhauls of government funding and oversight. More often, however, even the Chief Executive, who is ultimately responsible for what happens at the hospital or clinics, consults with others who have the necessary expertise and responsibility for key aspects of running the organization, such as the Chief Financial Officer, Chief Medical Officer, Chief Nursing Officer, Chief Operations Officer, technical specialists, and others. Consulting as a Type of Decision Making Decisions made through the consulting approach might include input gathered throughout the organization by talking with direct care staff— nurses, doctors, therapists, and other clinical staff members—along with frontline administrators and analysts to understand the impact of changes such as implementing more team-based approaches to patient care. Even though you may be responsible for the final decision, in most noncrisis situations there is value in receiving additional input, particularly to warn you if someone is aware of something that could cause problems, for example, a policy change that might put the organization at risk of decreased quality of patient care, legal problems, or other undesirable results. For example, hiring decisions usually involve others aside from only the manager to whom the newly hired team member would report. It is important that others provide feedback on their comfort working with the new person and buy into the decision to select and hire a particular candidate for the job. Others may offer varied perspective and notice “red flags” that signal something problematic about a candidate such as the possibility for patient harm or destructive conflict. So, even though the hiring manager may have the authority to make the final decision on selecting a person to hire, almost always a more inclusive process is used to arrive at the decision through approaches such as consulting (where candidates may meet other staff members who provide their input, but a smaller group makes the final selection), voting, or consensus. Even when you have the authority to make changes and implement new procedures, be careful to consider the perspectives of those who directly perform the work you are arranging. Consider this example from Marilyn Thomas Leist, EdD. She was an experienced manager who



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moved into a senior leadership position as Chief Operations Officer in a senior living and retirement community, her first experience in health care, with responsibilities for 24/7 operations. She wisely formed a council of high-performing staff to hear from them and gain perspective in their different areas of responsibility such as independent living, assisted living, dining services, and others. The nursing directors reported directly to Marilyn and helped her learn about medication management and managing staff with compassion. She oversaw workers’ compensation issues and took injured staff members’ needs into consideration by putting them on light duty. Things were working well with those approaches, until, in working toward the goals of her position to run things efficiently, she tried to reorganize housekeeping assignments—and was surprised when, in her words, “It bombed!” She was aware that the Certified Nursing Assistants (CNAs) become strongly attached to the residents they assist, but had not considered that housekeeping staff and residents also became friends. She learned that the bonds between residents and all the staff members they interacted with were strong; the housekeepers needed to make their voices heard about the change, and the residents needed preparation.17 The key to your success as a decision maker is to be clear up front about how a decision will be handled. Clearly communicate the process and establish the guidelines to avoid misunderstanding and disappointment later from your team members, which can undermine their support and willing commitment to following you in carrying out the decision. Allowing participation in the planning of changes might not alter the overall decision to make some changes, but it can help you make a better decision that ensures smoother operation of the activities for which you are responsible. Participative planning may take longer initially to gather a range of ideas and input, but it tends to result in better decisions that gain the support of those who need to implement and operate with them. And it will save you time in the long run by eliminating the need to go back and re-explain decisions, redo plans, and possibly apologize for failing to consider important perspectives of people doing the work. This is more time for you to move forward on doing the right things, with the full commitment and cooperation of your team members and others!

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Voting as a Way of Reaching Decisions While voting can be appropriate and efficient for relatively inconsequential decisions such as where to go to lunch or the color of the chairs in your waiting room, do not be lulled into a false sense of security by hiring a job candidate because the majority of your team voted for that person, especially if you, as the manager responsible for that person’s training and performance, have misgivings or feel uncomfortable working with that person. Similarly, in scheduling important activities, it may be tempting to vote on convenient dates and times, but be careful that you are not forced by this method to select a date when crucial participants cannot be available. In that case, you may need to extend the scheduling horizon or consider other trade-offs and negotiations to free up team members’ commitments. Be clear and careful in setting and communicating the parameters for decision making and acceptable conditions of the selected action. Keep in mind your option for “bounded consensus,” as described below. Consensus Consensus differs from voting in that consensus does not require that every member of a group or team has chosen a course of action as their favorite or best alternative, but the group members come together in a decision in which everyone accepts and agrees to support the decision. Mark Murphy (2014) offers these words of caution about how the illusion of consensus can make people angry when it suggests that people have more influence into a decision that will ultimately be made by someone else. He suggests that the actual decision maker should clarify the rules at the beginning of the process. State the purpose of the meeting, and acknowledge that there are many different good ideas that will be considered by looking at the pros and cons of each one. He recommends being clear and stating, “Ideally, we’ll start moving towards a general consensus, and maybe even achieve one. But in the event we don’t reach a full consensus, then I’ll weigh all the options and make a decision using everyone’s input. This ensures that we get everyone’s best thinking, but also gives us an escape valve so we’re not trapped in this room for 8 hours straight.”



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Murphy calls this approach “bounded consensus.” Although the leader may try to reach true consensus, it sets some limits and expectations, and offers the leader and decision-making participants an acceptable way out if true consensus cannot be reached in a reasonable time frame.18 This reflects Ken Bellian, MD’s, consideration of how we can make people feel good with teamwork and cross-collaboration. As he suggests, “You should always have your say but you don’t always get your way,” which means the final solution might not be exactly as each person defined it, but with everyone’s voice and input, “we built it together.”19 Whose Decision Is This? Ask Before You Act! Respect other people’s areas of authority and expertise. This includes hiring decisions that require review, approval, and procedures from your human resources department to ensure fairness in salary and benefits and compliance with employment laws. The decision might involve the organization’s spending and financial policies, or could require special expertise in technical areas such as information systems and technology. Do not assume because you have seen technology appear to be used seamlessly that a solution you want to promise to an external stakeholder will be quick and easy for your organization’s technical team to develop and deliver. There may be technical constraints and considerations that you are unaware of (such as incompatibility between electronic platforms or electronic security requirements) that prevent the delivery of what you have committed. Situations like these can erode trust and delay delivery of important project goals. It is better to ask before making commitments you might not have the authority or expertise to fulfill. In earlier sections we looked at how you conduct meetings, and how you record and follow up on decisions made there. Next, we will consider more about how to build integrity and get things done.

Honoring Your Commitments for Getting Things Done Dobson and Dobson (2000) advise, “Keep your word. Personal honesty is not only part of good character, it’s an essential ingredient in making your professional relationships work.”20 Gene Dankbar, MS, MBA, has

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worked with clinicians and managers for over 31 years at the Mayo Clinic. He noticed that strong leaders reached out to others to get their ideas, and they were strong in follow-up and follow-through. “They are doers, not procrastinators. They get back quickly, answer e-mail quickly.”21 What do you want people to say about you and your follow-through? Keeping your word requires that you be careful about the promises you make. Do not commit to something if you cannot or will not do it. It is best to under-promise and over-deliver. Make sure you are clear about the limits of what you agree to do—are you agreeing to help someone out just this one time in an emergency or is it something you will do regularly? Be clear about when you can deliver what the other person wants. Revisiting the Importance of Expectations Expectations can easily be mismatched with what is realistic if they are not clearly and openly communicated. Suppose the other person wants something today but you know you will not be able to get to it until the following week. Although it might feel more comfortable to avoid specific deadlines so you do not have to disappoint someone now, it is better to be clear about what you can and cannot do so you do not disappoint them later and leave them with the perception that you did not follow through on what they expected from you. Always summarize and confirm what you have agreed to. This allows you to address discrepancies and find solutions together that strengthen your relationships and improve results. If you know you do not have the time or the resources available to provide what the other person needs to meet his requirements, then it is best to be clear about that right away to enlist help from others or to renegotiate deadlines. Applying Expectation Management to Renegotiations Recognize that you will need to be flexible sometimes to adjust to changing priorities, and new requests, especially from your boss or other stakeholders who may have oversight authority. Be straightforward and try to negotiate for realistic schedules, and learn to accept graciously what you cannot change or negotiate.



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The Expectation Management Model, which we introduced in the previous chapter (and display again in this chapter in Figure 3.1), helps with such negotiations. Let us review the steps: 1. Identify the activity, behavior, or objective to focus on. These can be the behaviors and activities you expect of your team members, or quantifiable Key Performance Indicators. 2. Specify the target level of attainment. This sets your expected standards for performance. The target can be specified numerically or described in terms of desired observable behaviors. 3. Measure the actual level of performance. This could be numeric (metrics) or qualitative and subjective assessment through observation. 4. Evaluate whether the actual performance meets, falls short of, or exceeds the expected standard level. Also consider whether the target level is realistic and appropriate, not too easy or impossibly difficult, and whether the focus and objective are still appropriate. 5. Encourage performance adjustment if needed, and recalibrate objectives and targets as appropriate. 6. Continue to measure performance and facilitate adjustments as needed. Each step offers you an opportunity to clarify what both parties expect and define them in clearly recognizable terms to ensure alignment and open up productive conversation to recalibrate (as in Step 5) to adjust requirements if needed in changing conditions. Give-and-Take Support for Relationships and Commitments Building relationships can really help you with some balanced give and take. When others grant you favors, such as extending deadlines or loaning you resources, you should expect and willingly support them in turn when they need your help another time; perhaps, you could accommodate their needs or advocate for them with your other contacts who can help them get the resources they need. With that approach, you build your reputation for honoring not only your commitments but also the people who support you in fulfilling these commitments.

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Managing Your Time and Yourself Peter Drucker (1967) observed, “Time is the scarcest resource, and unless it is managed, nothing else can be managed. The analysis of one’s time, moreover, is the one easily accessible and yet systematic way to analyze one’s work and to think through what really matters in it.”22 Be mindful of the value of your time, its importance to you in your role as a manager, and the effects of your time management on your success. Dobson and Dobson (2000) advise, “Unless you can manage yourself, you’ll have little success managing others, whether down, sideways, or up. The choices you make about your time—how you spend it, how you prioritize it—are at the core of your self-management effectiveness. Since we’ve learned that your ability to influence others involves getting your own act together first, evaluate your personal time management on a regular basis.”23 Getting the Right Things Done Douglass and Douglass (1993) observe, “Time management is really self-management. If time seems to be out of control, it means that we are out of control. To bring ourselves back under control, we must learn new, more appropriate habits.”24 So, we wrap up this chapter by looking more closely at time management habits to support you in getting the things done that contribute to your success. As we have discussed earlier in this chapter, people come to trust you when you do what you say you will do, which means you deliver on your commitments. You were successful in your work as a clinician. You accomplished the goals and met or exceeded the expectations for you in your prior clinical role and that helped you advance into your role as a manager. Most likely, you had effective ways of keeping track of what you, as an individual, needed to get done and stayed on schedule with your requirements. Now, with your elevated and expanded responsibilities as a manager and your new responsibilities for overseeing the operation of your team and the results of the team members you manage, it is time to reevaluate your new responsibilities in terms of what you need to do along with when and how you will get it all done.



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The Importance of Goals: The SMART Approach Your success as a manager is a matter of directing your time, energy, and focus to doing the right things—the ongoing activities that are important to the success of you, your team, and the organization, and getting the right things done at work—accomplishing projects that may be time-limited and working on important and visible goals. Being busy and productive may signal that you are working hard, but if you are not directing your energy to the right things, you will not achieve the success you desire and may just end up feeling worn out or exhausted, especially if you are filling up all your time with activities regardless of their contributions to your goals. Douglass and Douglass (1993) emphasize the importance of goals as “the building blocks of better time utilization.” If you do not have specific goals and know what the end results of your activities should be, it does not really matter which activity you choose. “No matter what you do, the time will pass. One activity is as good as another.”25 Without goals, it is impossible to determine your priorities. When you develop your goals, write them based on the SMART ­criteria, established by Doran (1981) as: • Specific: With enough description to identify the area and desired results or level of improvement • Measurable: Quantify or describe the indicators of progress • Assignable: Be clear about who will work on the goal • Realistic: What results can realistically be achieved, given the resources available • Time-related: Specify when the results will be achieved.26 Some of the actual words in the SMART acronym have been adjusted and modified over time. • For example, “Achievable,” “Attainable,” and “Actionable” are often substituted for the original “Assignable.” • “Relevant” is sometimes used to emphasize alignment with other priorities or meaningfulness to those who are working toward the goals.

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• “Timely,” “Timed,” “Time-limited,” and similar words have been used to capture the importance of prompt startup and keeping track of time and due dates in working toward completion of goals. The point is that your goals need to be specific enough to work as effective guides in planning, making, and tracking progress. This helps keep you on track and provides visibility to hold team members accountable and motivated in accomplishing agreed-upon goals. Organizing your goals and tracking your progress on them builds a foundation for effective communication with your boss, who can help you ensure you are working on the right things that align with her priorities and organizational goals. She also can help you identify and clear any roadblocks to expedite your progress and support your success. We will see more about managing your important relationship with your boss in the next chapter. Time Management Techniques There are several popular approaches to managing your time to ensure you accomplish your goals. Because interview participants referred to several different useful frameworks and techniques that you may hear about from your team members and other people you work with, we review some major ones and explain their evolution and importance here. Peter Drucker, in his book The Effective Executive (1967), dedicated the second chapter to his advice to “Know Thy Time.” He recommends starting not with your tasks but with your time. It is particularly important to understand where you are actually spending your time. He believed the foundation of executive effectiveness involves the three steps of: • Recording where you spend your time • Managing time to cut back on unproductive demands on it • Consolidating time to allocate the right duration to focus ­effectively on the important tasks.27



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Early in the field, Alan Lakein titled his pioneering book on time management, How to Get Control of Your Time and Life (1973) and introduced the ABC method of prioritizing that sorts activities into: • A: “Must Do,” things that have high priority because they are very important, critical items, with close deadlines • B: “Should Do,” things that are important to do over time and have medium priority at the moment because they are not as urgent as A items • C: “Nice to Do,” things that have low priority at the moment with low consequences if left undone. This ABC sorting helped answer the important question Lakein reminded readers to continually assess, “What is the best use of my time right now?” The enduring idea is to continue to focus on your A-level items before moving to your B list, and do not do the C items while you have higher-priority demands on your time.28 This remains an important question for keeping your priorities in mind even as the field of time management has evolved to the principle-centered work of author Stephen Covey. One of Covey’s books, The Seven Habits of Highly Effective People (1989), was mentioned frequently in conversations with our interview participants, and was included in Covert and Satterson’s (2009) readers’ list of top ten business books.29 Covey’s approaches can help you identify your principles and ethics, distinguish urgent but not important requests from the activities that are truly important for your goals, and establish practices that become habits and lead to your success as a manager of others and yourself. Covey describes effective self-management in the context of independent will as the “ability to make decisions and choices and to act in accordance with them. It is the ability to act rather than to be acted upon, to proactively carry out the program we have developed.” He explains how this involves the discipline to practice the habit of “putting first things first” to “organize and execute around priorities.” The challenge, he believes, is not to manage time but to manage ourselves, to say yes to the right things, the

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truly important priorities, and no to other activities that are less important and detract from your time and energy.30 Covey presents a Time Management Matrix that divides tasks into four quadrants that represent: • • • •

(I) Tasks that are Important and Urgent (II) Tasks that are Important but Not urgent (III) Tasks that are Not important but Urgent (IV) Not important and Not urgent.

Covey’s approach differs from Lakein’s in that he does not consider Quadrant II to have lower priority than Quadrant I. He explains how the apparent urgency of tasks in Quadrant I, which tend to be problem- and crisis-oriented, can consume your energy and lead to ineffective habits of being reactive and crisis-driven, with recurring waves of problems that never subside because you are not dedicating time and focus to proactively initiate important opportunities. Quadrant II activities include planning, building relationships, and working on effective activities that help prevent the problems that demand your attention in Quadrant I. As more time is spent in important but not-­ urgent activities in Quadrant II, less time will be needed to react to the reduced number of important and urgent crises and problems in Quadrant I. The important question becomes, “What one thing could you do in your personal and professional life that, if you did it on a regular basis, would make a tremendous positive difference in your life?” These are things in Quadrant II, where “our effectiveness takes quantum leaps when we do them.”31 More recently, Brian Tracy (2017) revised and extended the ABC ­approach to ABCDE: • A tasks are very important, with serious negative consequences if you do not do them. • B tasks are important things that you should do but less important than your A tasks with less serious consequences if they are not completed. • C tasks are “nice to do,” less important than A and B tasks, with no negative consequences for not doing them.



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• D tasks are those that you can delegate to someone else who can do them instead of you. • E tasks do not need to be done at all! If you can eliminate these activities, you should do so to free up your time. Tracy explains that this approach helps you to sort out very easily what is important from what is not, so you can focus your time and attention on what you really need to be doing. “Once you can clearly determine the one or two things that you should be doing, above all others, just say no to all diversions and distractions and focus single-mindedly on accomplishing those priorities.”32 Yes, you have more new and important responsibilities now that you are a manager. The expanded ABCDE approach opens the possibility that maybe you do not always have to do everything on your list immediately. Or maybe everything does not have to be done directly by you. As we discussed in Chapter 2, it is important when you begin to take charge to recognize when it may be most appropriate to delegate some activities that do not require your particular level of skill, expertise, or authority. Delegating them to others on your team can get things done faster while helping them to develop their skills and experience. And if you and your team are taking extra steps that do not add value for patients or the organization, you might have opportunities to improve efficiency and responsiveness by cutting out time wasters that really do not need to be done at all! However, be very mindful to avoid making unwarranted decisions about what is and is not important to do. You might think some of that frequent handwashing or extra details you enter in your patients’ records are not always necessary, but your safety and quality staff might think otherwise and know of important reasons why some activities are necessary for the health and safety of patients and fiscal health and compliance of your organization. If you are thinking about changing work flows to eliminate some steps, it might be time to reconsider our sections above on how decisions are made and whether they are really yours to make or ultimately someone else’s responsibility to make and approve. When making changes, it is always important to consider who else needs to know about them because they or their areas of responsibility are affected by the changes. In any case, isn’t it a relief to see how freeing prioritizing can be?

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Habits and Systems to Support You in Managing Time and Commitments Allen (2001) offers another freeing approach by helping you get things off your mind and into reliable systems that help you take the right actions to achieve your goals. Using a reliable system, stored outside your mind and with reminders that you cannot miss, reduces the stress of thinking about things at times when you cannot do anything about them, and ensures that you do not miss following up on something you need to do. Do these things: 1. Get in the habit of capturing into a reliable system outside your mind everything you consider unfinished. 2. Clarify what your commitment is, what actions you need to take, and their schedule for you to fulfill the commitment. 3. Keep reminders of all the actions you determined in the step above, organized in a system that you review regularly. The keys are to: 1. Free up your mind of all the details so you can focus on your priorities, 2. Use your external system as a focal point to revisit regularly.33 Make sure you have and regularly use a system for follow-up and review. A “tickler system” sets up reminders for the future, for instance, with lead time before due dates.34 The Weekly Review is a critical success factor. It is the time to gather and process everything you have collected, review your system, update your lists, and become “clean, clear, current, and complete.”35 Timeliness and Visibility Be sure to allocate and adhere to regular times to review and process the activities you have collected; this helps you avoid building up backlogs that obscure your important priorities and detract from your timeliness



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in making decisions, responding to and communicating with others, and taking needed actions. Choose a time that works for you. I have had colleagues handle this successfully at both ends of the spectrum. One who was particularly effective in managing e-mail left the office early to pick up kids in school, and then revisited each day’s accumulation at night after she had put the kids to bed. Another was disciplined in getting to work an hour early every day so she could review open items and plan her day before others arrived and meetings began. Others have used long commute times on public transit to plan for the coming day on the way to work and process remaining e-mail and action items on the way home. Some people block out time Sunday night to address items accumulated during the week and plan for the coming week.

Consolidated Tracking If you do not already have a consolidated place to track your activities, when you adopt one it will help you feel confident and stay organized, which will increase your effectiveness and reduce your stress. Technology can be very helpful, especially electronic calendars with shared access for appropriate team members. This can provide visibility to enhance communication and promote scheduling efficiency that helps prevent scheduling conflicts. I love accessing my calendar from anywhere on my smartphone to know where I need to be, how to get there with mapping apps, and to update activities and appointments. For keeping notes in one consolidated and easily accessible place, even a simple paper notebook can be very helpful for keeping you organized. I still see many technically adept people use this “classic” (low-tech) approach to jot down notes, while others enjoy portable electronic devices. A former colleague of mine wrestled with paper and overwhelming feelings of disorganization until he finally invested in a small electronic tablet and cleared his office of all the paper by scanning what he wanted to keep and storing it in a cloud-based system, and shredding or recycling the rest. He found his new uncluttered office to be conducive to his concentration and productivity, and spent less time searching for documents. The office even looked larger and more inviting to work in! His unfettered

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approach to tracking and organizing quickly became a habit that he was never tempted to curtail. Apply Discipline and Consistency The books referred to in the foregoing text are several among the many resources available to help you find and practice effective ways to manage your time and activities. The key point is that you find or develop methods that work for you to leverage your energy into being an effective manager, and then practice them with discipline and consistency so they become habits. Keys to effective time management are: 1. Clarifying your priorities 2. Setting goals 3. Tracking your progress toward your goals 4. Being realistic in allocating and scheduling your time 5. Regular reviews and adjustments Review and Adjust Regularly Planning and goal-setting are not one-time activities but something you should regularly review for relevance and progress. This is where it is important to clearly identify your responsibilities from the perspective of your boss and always consider how your activities align with organizational goals. And remember to consider the values of your team members reporting to you and those of your colleagues and other stakeholders. This means you need to carefully review your activities and requests regularly. First identify the few key things that are critical to your success, realistically determine how much of your time you need to spend on them, and block time into your schedule to ensure you make continual progress on them to get them done. Pick times when you know you are most productive for the kind of work required. Some people find they have the most energy first thing in the morning or approaching the evening when other activities have settled down and there is more quiet time available. Some people block out days of the week to focus on the work that requires focused time working on specific



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projects or activities. The actual times these occur is not as important as ensuring that you allocate and protect adequate time to dedicate to these crucial activities. Make sure you pick times and days that can be reasonably supported and accommodated most of the time by other organizational activities and priorities. If Fridays are a quiet day in your clinics or office, that might be a good day to block out some time. Conversely, Mondays tend to be busy days in many clinics with patients calling to address needs that arose over the weekend, so you might avoid choosing that day to focus on your administrative projects and tasks.

Managing My Time and Myself: What I Have Learned and Recommend Remember, it is not about how much activity you spend time in, it is the results and what you accomplish while developing constructive working relationships that count! I offer these tips for you to consider, from my experience in managing my time and learning to do things better: 1. Build and value your working relationships. They foster teamwork, make your work life enjoyable, help you get things done, and build the groundwork for you to be able to negotiate when you need to. Be willing to give and receive help and negotiate with others to meet your needs and those of your teams, organization, and the patients you serve. 2. Make sure you allocate time and energy to people and activities you enjoy for your well-being, renewal, and sustaining the relationships you value in your life. 3. Managing your time and activities is not only about planning and setting goals in your mind. Working toward your goals (long- and short-term) must also get scheduled into your work and other activities. Write down the key things you plan to do; this reinforces your awareness and commitment to actually do them. Put them into your calendar or work schedule, with time allocated to actually doing the necessary tasks and details, along with regular recurring times to review your plans and progress toward them.

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4. Find or develop a simple, consolidated, and accessible place for you to record important activities and reminders. This will save time and reduce stress in trying to locate important details when you need them later. a. For me, keeping a paper notebook handy provides a convenient place to jot down notes, record action items for follow-ups, highlight relevant pieces of conversations, and keep track of agreements. I date each page or entry, so I can quickly locate and review with colleagues the details of activities along with the schedules and deliverables we had agreed to. This is not a substitute for more formal and detailed plans, but I find it helpful in keeping track of day-to-day activities, and several of my colleagues found it helpful to refer back to the notes they had seen me take. b. Technology is great; just make sure any devices you use are charged and that you have access to any required networks or remote storage locations. If you are working away from the office, make sure you have mobile access to the Internet and remote access to any central storage you need. I create electronic reports, plans, charts, graphs, and other documents, and store them in accessible electronic folders that I can easily find or search for electronically. 5. To be truly effective in achieving your goals and sustaining your productive momentum over time, it is essential that you do not overschedule your time and do not overcommit to what you realistically can handle! a. Be careful about the commitments you accept and the activities you spend your time on. If they are not important or necessary, conserve your efforts for those that are. b. Be realistic about how much time is actually required to get things done. Avoid scheduling based on optimistic estimates. Allow some extra time into your due dates and schedules, especially if you are learning things for the first time or you need to rely on other people and circumstances beyond your control. 6. Expect the unexpected—that means preserving some open time in your schedule to handle the other ad hoc things that come up. These are things you do not know about ahead of time, but you may be required to do them because they are urgent and important to someone with authority or important to you and your organization. For



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example, you will be expected to handle crisis events and respond to important urgent requests from your manager, those at higher levels, or important external stakeholders. 7. Be open, aware, and proactive. You might be offered or discover opportunities that feed your professional development and interests, and you do not want to be so overscheduled that you cannot work them in without dropping other important commitments. These could include joining a key committee or a task force in your organization or greater professional community, presenting a paper or workshop at a professional conference, or troubleshooting to resolve a problem that requires your special expertise. 8. And finally, remember that you do not always have to do everything yourself. It is healthy and appropriate to delegate things that do not require your level of expertise or special skills, or that provide valuable learning and professional development to those you supervise. In Volume II, Chapter 2, we will consider more about hiring and managing your important human resources: your team members who report to you, contribute to your team’s and organization’s success, and thrive with your capable management!

Chapter Summary and Key Points In this chapter, we focused on how to plan and organize to support your successful handling of your new responsibilities. This includes planning and leading meetings and following up to ensure that the agreed-upon activities are accomplished. We revisited the importance of delegation so you are not doing everything yourself and you are helping others develop their skills. We looked at how decisions get made and when to apply different approaches. We reviewed the evolution of time management techniques and offered various approaches you may find useful. Key Points: 1. Be proactive in deciding what you need and want to accomplish in your new management role. 2. Set up a regular schedule to meet with your team and individual members. 3. Plan your meetings and run them effectively

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4. Structure proposals for action before meetings to solve problems efficiently. 5. Develop specific goals and plans. 6. Track progress on your goals. 7. Be decisive; balance speed with participation and elicit participation as appropriate. 8. Choose an approach and schedule time to manage your incoming and ongoing work. 9. Be judicious in accepting commitments and diligent in fulfilling them. 10. Expect and contribute to balanced give-and-take relationships with colleagues to contribute to organizational success. 11. Manage the expectations for what you can deliver in fulfilling commitments to others. 12. Be realistic in your time estimates and avoid overscheduling your time. Remember that changes will arise that are outside your control and you need some room in your schedule to respond to them. 13. The Expectation Management Model can help you evaluate and renegotiate reasonable deliverables when situations change. 14. Delegating and involving others can help you and others grow with evolving opportunities.

Learning Activities for This Chapter 1. List the meetings you currently participate in or lead. a. What do you suggest for running them more effectively? b. Review the structure of the meetings you lead most often. How is the agenda working? c. Use the meeting agenda form in Appendix B (Table B1) to plan one of the meetings you lead. d. What items would you like to add or delete? e. How are decisions and action items recorded and communicated in your meetings? What could you adjust in your meeting agendas or notes that could help improve these?



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2. Pick an idea you have for a problem to address or something to improve in your organization. a. Describe what you would like to propose to others to accomplish this solution, using the SBAR format: i. What is the current Situation? ii. What is the Background: factors or statuses that are relevant to the situation because they contributed to the current status or need to be considered in the solution? iii. What is your Assessment of possible courses of action? What do they involve, what are the costs, pros and cons? iv. What is your Recommendation for how to proceed? b. How will you prepare and present your SBAR? Is there an existing meeting where it should be sent ahead of time and discussed in the meeting, or is there another forum that exists, or you will need to create? 3. Time management a. What approaches from this chapter would be beneficial to you for managing your time and commitments? b. What times and days would you pick to plan and review your work and commitments? c. What will help you establish habits and routines to ensure that the system you choose will support you effectively? Consider technology and nontechnical approaches, and the existing routines you need to work with or adjust to better meet your needs. d. What activities are you keeping track of in your head that you could handle more effectively by writing or storing the details somewhere else? Select and try a more systematic approach as discussed in this chapter. 4. SMART goal exercise: Pick three goals and apply SMART planning to them: a. One that is important for the team you lead to accomplish together. b. One that is important for your professional development as a health care manager. c. One that you value personally that will enrich your personal life or work–life balance.

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5. Consider a decision you made or were involved in at work. a. Which approach was used: Command, Consulting, Voting, or Consensus? b. Why was that an effective approach for the situation, or why would you recommend a different approach? Were there ­unexpected consequences or useful results of the approach that was used?

CHAPTER 4

Managing Up, Down, and All Around! Chapter Overview Being a manager involves supervising and leading the team of people who report to you, and communicating clearly what you expect them to do. 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 your successful transition to administration • Chapter summary and key points • Learning activities for this chapter

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Your New World and Who Is in It Your role has changed relative to those around you, and this changes your relationships. In Chapter 2, we considered new dynamics that emerge when you move to a position of responsibility for a team or group of your former teammates and peers. Or perhaps you were hired into the organization to manage people who were already working there. In any case, your new role as manager requires you to take charge, acknowledge additional power and authority you now hold, set expectations for your team and meet the expectations for your performance. You are learning to lead by understanding the values of those who now report to you and leveraging areas of alignment. Now, let us broaden your scope. Who else do you need to consider as part of your new world? Current articles refer to the need to manage up, down, and sideways. Thomas Barta and Patrick Barwise (2017) found evidence that managing upward and horizontally can improve your business impact and career success. They specifically mention the importance of your bosses and forging strong ties with your colleagues to build momentum.1 And what about important other people? They can include peers, customers, outside regulators with authority over your organization, patients, and their families. Strayer (2017) includes “managing outward,” where, “Relationship building and active communication are essential, especially when timelines are tight, whether your customer (who receives your output) is external or internal to your company.”2 The Value of Relationships Up, Down, and All Around Consider what relationships you have or need to build. As you work through this chapter, consider what is expected between you and others in these relationships, and how to foster collaboration with others from the perspective of your new role as manager, leader, or administrator. For Erica Snow, MS, MPA, the relationships she built helped her succeed in her role as a quality improvement coordinator and then as she advanced to manager. She worked internally to enlist the support of clinical managers to promote the use of quality improvement methods with their teams. Her external relationships, along with her growing content



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knowledge of health care operations and funding, led to new career opportunities with increased responsibilities. She was recruited to join a health care funding foundation through her professional network, which she had expanded by participating in several leadership fellowships, which are particularly helpful in building a broader base of professional relationships. When I interviewed her for this book, she reminded me that as her boss at the time, I had written a recommendation for her for one of these fellowships.3 I remember how I had enjoyed working with Erica and appreciated her valuable contributions to our team and organization. This made it easy for me to support her in activities to help her advance her career and contribute to broad goals for health care access throughout our community. Now let’s explore more about your relationship with your boss and how managing upward can enhance your success.

Managing Up: Your Important Relationship with Your Boss Your boss is a particularly important person in your work life because this is the person who can help you learn and develop your capabilities, facilitate your access to helpful resources and opportunities, advocate for you and your advancement, deliver rewards for your good performance, and determine consequences if you do not deliver what is needed or desired. So, let’s start with this important relationship. Dobson and Dobson (2000) explain, “We can’t accomplish our work and our objectives without the willing and voluntary cooperation of numerous people over whom we have no direct control.”4 You need to build a relationship with your boss which results in mutual success that includes being listened to, having your ideas respected, getting timely decisions from your boss, and building your influence to help you get your job and goals accomplished.5 Getting Clear: Who Do You Report to? We have seen examples of complexity in health care organizations and evolving rules about leadership and responsibility for the activities of

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others. So, it is important to clarify who your boss is. Who do you report to? For consistency, we will refer to this person as your boss, although the actual title is something else such as Team Leader, Supervisor, Manager, Director, Associate Administrator, or perhaps even Vice President or Chief. This is most likely the person who had the final say in choosing you for your position, although the Human Resources department was likely involved in discussions about salary, benefits, and other administrative aspects of your position, and other team members may have participated in your interviews when you applied for your new position. Your boss is usually the person who approves of your administrative activities such as work time scheduling, time off, time reporting for payroll, expense reports, and other expenditures, depending on your level of budgetary authority. This is also the person who holds you accountable for achieving the goals and results expected of you in your new managerial position and offers praise and formal rewards or delivers corrective feedback and disciplinary actions related to your performance. How You Support and Value Your Boss Dobson and Dobson (2000) suggest that you develop a productive and mutually beneficial experience for you and your boss by providing support and showing that you value him. “When you feel that you are supported and valued, it’s easier to take—and even welcome—feedback and suggestions for change and growth. Demonstrate the same behavior upward that you appreciate and value downward.” Managing up is not about manipulating your boss. No one likes to feel manipulated or used by others to get their way. Rather, it should involve helping your boss to be effective and productive by supporting him to help him stay organized or fill in areas of weaknesses, looking out for his needs, and providing truthful feedback when needed.6 Keep in mind that you and your performance reflect on your boss and her capabilities. As Shari Harley (2013) reminds us, “Your job is to make your boss look good.”7 Your boss has a boss, too, and other customers and stakeholders judge the results and effectiveness of activities in your boss’s area of responsibility. As a new manager, your work should demonstrate that your boss made the right decision in choosing you.



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Loyalty and Respecting the Chain of Command Dobson and Dobson explain the importance of loyalty to your boss, and the need for you to manage this key relationship. In particular, you need to understand and respect the chain of command. As Dobson and Dobson (2000) explain, “Violating the chain of command means to bypass one or more intermediate levels of supervision to get job assignments or decisions from a higher level. Although it may be tempting as a short-run strategy, especially if you’re not getting the support you need or want from your immediate boss, this behavior has several drawbacks: confusion, bad decisions, or mistakes. Each level of the chain has information and goals. Bypassing the chain cuts that information out of the process.” It is like playing off parents against one another to get the decision the child wants. It shows lack of loyalty to your boss, and lack of understanding about organizational structure, both of which can raise the concerns of others about you for doing it.8 Relationships you may have developed with those above your boss are fine for special projects and assignments, mentoring, and networking as long as your boss was properly informed and consulted. Do not collude with others who go around your boss. Do not deliberately keep your boss out of the loop; it is your responsibility to direct decisions and information back to your boss. Dobson and Dobson (2000) warn, “Don’t use these relationships to reverse your boss’s decisions, get job assignments without your boss’s approval, or keep your boss in the dark about those relationships . . . . Note that if your boss feels bypassed by his or her own boss, feelings of paranoia and persecution may result . . . so you may bear the brunt of your boss’s resentment.”9

Detect and Avoid Loyalty Problems Occasional emergency or crisis situations may require bypassing normal channels of communication, agreement, or approvals when there is urgency needed to prevent serious consequences. However, most normal activities and decisions are handled more appropriately by respecting appropriate channels of communication and decision making; otherwise, confusion and weakened trust become unwelcome characteristics of the workplace and can detract from safe and coordinated care for patients.

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Keep Your Boss in the Loop on the Things She Needs and Wants to Know About These include things that require her support or approval, such as incurring significant expenses, or significant deviations from regular policies. Find out when you start in your position what the procedures are for spending money, and your level of budgetary and sign-off authority. This can vary with the organization—in some, a supervisor has visibility and access to a team budget and has the authority to make or approve expenses for the team he leads. In others, directors do not have direct access to a budget that rolls up to a vice president, so even a director must ask the person she reports to for support and approval of expenditures. Keep in mind that even if you develop good relationships with senior leaders above your boss and their level of approval is necessary to sign off on something, you need to make sure your boss knows what you are requesting and supports the project. Most bosses do not like surprises about major things happening in their areas of responsibility that they were not aware of! Nor are they happy about having to support a decision made by someone else who did not have all the facts or expertise needed to ensure that things work as intended. Remember, part of your job is to help your boss succeed. Your boss influences many factors that can make your working life better or worse. It is in your best interest to support rather than alienate this person. Keep Your Boss Informed Let him know about the activities and progress of you and the teams that you manage, especially when they are nonroutine, have the potential for particularly high impact, or something is going wrong. This helps your boss manage resources effectively, ensure alignment of activities to support the organization’s goals, provide guidance when needed, support your efforts, warn the senior managers above him, and communicate with other internal and external stakeholders who may be influenced by your team’s activities. When things are going well, this is your chance to shine by communicating your team’s successes and recognizing your team members for their



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good work and contributions. When there are problems, involving your boss appropriately can help you turn things around effectively, minimize damaging outcomes, and can even deepen your boss’s respect for you and earn you the reputation as an effective problem-solver who takes responsibility and does not avoid the difficult issues. Find Out by Asking What Level of Involvement Your Boss Wants Some bosses like to be included in your communications, such as being copied on e-mails for their information, especially when you are new and getting started in your position. Others prefer that you just handle the routine details of what you are doing unless there are special circumstances. When you are new or in doubt, it is better to overcommunicate until you are confident that you have hit the right level of what works for your boss. Include him a few times and check in to ask whether he wants to know about such issues or not. You might simply say, “I copied you on my message on pharmacy planning in case you’re interested in my team’s interactions with others. How much information would you like to receive about communications like that when they’re in the initial stages? Do you want to see these messages or just hear about results or problems if they arise?”

Aligning with Your Boss’s Goals and Needs As Dobson and Dobson (2000) point out, “Doing the right thing and doing things right aren’t just measured by you. Your boss legitimately has a lot of input in deciding what ‘right’ means.” Those authors further explain that the importance attributed to work activities is a “negotiated product” consisting of the perceptions of your boss and senior managers above your boss, your coworkers, and your customers.10 “Doing good work means not only delivering quality performance, but sometimes more important, knowing what quality performance is.” A good place to start is to review your job description, make sure you understand performance standards and how you will be measured in your work toward

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them, determine how to allocate your time and effort, and ask for feedback to ensure your plans are in alignment with what your boss thinks is important.11 What is the best way to ensure that you are meeting the needs and expectations of your boss and others? First you need to understand clearly what those expectations are, and the best way is to ask directly. Shari ­Harley (2013) emphasizes why this is so important: “Ask how you’re being evaluated. If you don’t know how your performance is being measured and what a good job looks like, you might meet your manager’s expectations and, then again, you might not.”12 Health care settings are very complex, filled with standards and requirements that may seem to conflict and compete, and where interpretation of priorities can seem ambiguous. It is essential that your activities align with the expectations of your boss to support the goals of your organization. Do not assume and leave this to chance! As Harley further explains, “When organizations are aligned, your annual goals are ultimately a portion of your manager’s goals . . . . What you think is important may not be what your manager thinks is important. Work on agreed-upon priorities to avoid major frustration later.”13 Checklist to Ensure Alignment When you begin in your new position, or are assigned to a new boss, gather these items and review them with her to ensure that you are in alignment in your expectations of your responsibilities, activities, and performance. 1. Your job description. Pay particular attention to duties and responsibilities and make sure you agree that the list of major activities is complete and descriptions are accurate. 2. The performance review form and criteria used in your organization. Verify with your boss that this, or another format, is what she plans to use. Make sure you are aware of how your performance will be reviewed, the expected standards, and rating criteria for your performance.



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3. Other performance standards for the organization and your team that you are expected to manage and deliver. These might be part of strategic and operational plans established at the organizational level or by specific departments. 4. Time-limited projects and their goals that you are responsible for meeting. 5. A list of other things you are working on that are not included elsewhere and contribute to the success of your team, department, goals of your boss, and the overall organization.

Organize Your Activities to Review and Track Progress In the previous chapter, we examined the value of making plans and setting goals. We considered why it is important to write your goals down and communicate them with your boss. Let’s take a closer look now at how you could structure and present your activities in a way that shows what you are focusing on and your performance in achieving what you believe is expected of you. This demonstrates that you are goal-oriented, accountable, and respectful of your boss’s time because you took the time and initiative to organize the information succinctly before meeting with him. Create a table to keep track of the key things you need to review with your boss, at least initially, to ensure your priorities for your activities and efforts are aligned with his. Presenting specific information in a format that is clear and easy to comprehend sets the stage for managing expectations by clarifying exactly what levels of performance are expected and being achieved by you. This helps with evaluating progress and recalibrating objectives or target levels of performance if needed. We explained such actions through the Expectation Management Model, introduced in Chapter 2 to set and manage expectations, and applied in Chapter 3 to follow up on decisions, commitments, and negotiations about expectations. Here is an example of a format you can use or adapt to the needs of your particular organization and responsibilities (Table 4.1).

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Table 4.1  Example table of activities to track and review Source (where is this identified and assigned Current Other, to you or Performance ­performance ­comments, Responsibility your role?) expectation Measured by level plans To complete patient admissions

Job description, operational plan

20 new patients per week

Weekly admission reports

Average = 22 patients/week since hired on July 10, 2018

Patient External satisfaction with ­accreditation admission for standards treatment

95% of patients satisfied or highly satisfied with services

Patient ratings reported by an external survey organization

To be collected— survey due January 10, 2019. Level before hire = 89%.

Insurance information completed

Job description, operational plan

100%

Monthly 92%, 6-month revenue cycle moving reports average as of August 31, 2018

Admission representatives are being trained to complete insurance information fully

Hiring nurses

Job description

Vacancies filled within 30 days of opening

Monthly staffing reports from Human Resources

Average of 28 days to fill vacancies, reported in past 6 months

Connecting with the local university’s nursing program has been beneficial

Employee satisfaction

Performance review

At least 90% of direct reports are satisfied with their manager

Survey data from external measurement organization

New standard, to be reported in next survey in January 2019

I’m gathering informal feedback to track issues and progress on improvement

Develop employee leadership training class

Department’s Ready for operating employee goals enrollment by February 1, 2019

Progress tracked on monthly progress report

Materials 75% complete. On schedule

Progress tracked on monthly progress report

Membership confirmed by 9 of the 12 required family members

Implement new New family advisory statewide board initiative

Recruit 12 family members to meet by December 1, 2018

The team is gathering feedback from new patients on how to improve the admission process

Managing this project in the interim until a new family advocate is hired



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Gauge the Amount of Detail Needed Be alert to your boss’s preferences for high-level vision versus details. Start with the smallest number of activities that covers the important priorities and columns needed to keep track of them. Follow your boss’s lead in adding additional information she asks about, or eliminating what she finds extraneous or irrelevant. Retain what you need for your own effective tracking to make sure you are meeting the expectations of your boss and other people or functions you are accountable to, and streamline if needed for productive conversations with your boss. Watch for nonverbal cues, such as your boss looking overwhelmed, distracted, or uninterested, but do not make assumptions. To verify that you are on target, ask if the format and information you are providing is helpful and whether your boss prefers a different way of organizing it. Asking for and utilizing feedback is essential to your success, and you need to gain comfort and proficiency in having such dialogues not only with your boss but also with other people who work with you. After all, how can you correct problems or improve needed skills that you are not even aware of the need to address? In Volume II, Chapter 2, we offer some specific ways for you to request and receive feedback. Review and Negotiate Having something written down for you to review together can help you and your boss ensure you are both aligned in your focus and expectations. Notice Table 4.1, the example table of activities, includes some projects and activities that are not in the job description. Including them helps keep your boss aware of ad hoc assignments you may have been given or volunteered to handle that are not part of your official job description and were not assigned by your boss but require your time and commitment to complete to meet someone else’s expectations. You may need to negotiate with your boss some trade-offs to add or delete some responsibilities to best align with her expectations for what you deliver. You may discover together some opportunities to delegate some of your responsibilities down to your team members or sideways to other colleagues. The guidelines for delegating that we covered in Chapter 2 can be applied in delegating to others who do not report to

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you to make sure there is clear agreement about what you are requesting and what they are accepting and agreeing to deliver. And, when they do not report to you, you need to rely even more on your ability to influence others to accept assignments or fulfill commitments in the spirit of working collaboratively with you to achieve organizational goals together.

The Importance of Influence You need to influence, rather than force, others to want to work collaboratively with you. In the words of Dale Carnegie, “The only way on earth to influence other people is to talk about what they want and show them how to get it.”14 Although it was written initially in 1936, C ­ arnegie’s book, How to Win Friends and Influence People, remains so popular that it was one of 10 books listed in a reader poll for a book published in 2009 on the 100 best business books of all time.15 As Carnegie points out, each of us is interested in what we want. Most of the time, managers really cannot make anyone else do anything unless the person wants to do it because it fills his needs or she is motivated for her own reasons. When people report to us, they are likely to do what we request of them if they need their jobs or are motivated to continue being employed in our organization or led by us. Jackie Attlesey-Pries, Chief Nursing Officer at Boulder Community Health, explained that when people do not report to you, rather than exerting control over them, you need to inspire people to direct the work.16 Leadership Helps You Manage Effectively Clearly, the complex world of health care requires managing many different activities and work done by other people along with the things you still do directly yourself. Armstrong (2013) describes management and compares it to leadership. Management, he explains, is about obtaining and applying resources, including people, money, facilities, equipment, information and knowledge. Leadership focuses on people. “It is not enough to be a good manager of resources, you also have to be a good leader of people . . . . To lead people is to inspire, influence and guide. Leadership involves developing and communicating a vision for



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the future, motivating people and securing their engagement. It is an influencing process aimed at goal achievement.”17 Several people mentioned in their interviews the role of confidence and trust in your development as a leader. As Chris Noonan, CEO Group Chairman at Vistage International, says, “Show up as a leader and people will follow.”18 Mary Peelen, Director of Health Information Systems Management at the Mental Health Center of Denver adds, “If your leader talks about things and you trust her, you follow.”19 Leadership skills also help you when you are in situations as a manager or administrator where you do not have direct supervisory responsibility over other people working with you. These could include organizational activities or projects where you are accountable for the results in important aspects of health care such as service quality, treatment outcomes, compliance, record-keeping, or patient satisfaction, which involve multiple teams and departments with people who do not report to you. Since you do not have direct authority over these people, you need to become effective in influencing them and collaborating with people coming from different clinical disciplines and areas of responsibility. What about other people who work with you, when you have no official authority over them to require them to cooperate with you? This is the key to managing all around, where you rely on your relationships and influence with other people who do not report to you. The following examples from interview participants show how they lead effectively with influence. Leading with Influence Instead of a Title When Trista Ross, PharmD, was an intern, she needed to complete an internship project, which was to improve customer satisfaction. This required “leading without a title.” She didn’t have positional authority to require people to support and participate in her project. Instead, she engaged people to really rally around it. She made candy bags with survey reminders and gave them to pharmacy customers as they picked up their prescriptions. The pharmacy manager participated in distributing the bags and surveys, and it caught on through his leading by example. The project was very successful with all the support Trista enlisted from people who worked in the pharmacy and did not report to her but wanted to help.

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Satisfaction scores went up because there were more positive responses, not just from the unhappy customers who sought to complain via the satisfaction survey. Feedback was actionable; for example, a customer complained about long wait times, which the team addressed.20 Thus, even though as an intern she did not have official control over others, she was able to inspire positive change in the organization. From Command-and-Control to Matrixed Management Preston Simmons, DSc, MHA, FACHE, described the shift from command-and-control approaches that were taught in earlier medical education toward a more “matrixed environment,” which refers to people following leadership and direction from people who do not have direct authority over them but still are responsible for the results of teams that work together to accomplish their shared goals. When leading in these current structures, it is important to work with and through others.21 This means influencing, guiding, and empowering others rather than directly telling them what to do. Several doctors elaborated on these approaches. Michael Sullivan, MD, observes, “A leader is a change agent. The challenge is in getting people to believe and own the change; otherwise, they might comply but the change isn’t sustainable. When physicians take charge and tell people what to do that isn’t being a change-leader.” He explained the need for humility and insight to work with staff from other professional disciplines. “The most successful understand that the power doesn’t come from the degree.”22 Collaborative Communication to Influence and Engage Participation Recognize and value others; you need them to work with you to support your goals and collaborate with you to achieve shared visions and goals. Michael Ward, MD, PhD, strives for open communication in the clinical teams he leads to ensure that everyone’s input and concerns are heard. He values feedback from all members of the team and actively encourages members of his team in other clinical disciplines to bring forth their perspectives, especially if they notice something that could get in the way of safe and effective treatment for the patients the team treats.23



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Ken Bellian, MD, MBA, recommends engaging others through communication that recognizes their roles and how they contribute to organizational success. For example, translate the organization’s strategic plan up and down so everyone understands his and her role. You could talk with the person who cleans facilities about his role in patient experience, patient safety, and quality metrics. Then he would understand the importance and value of his contributions in preventing surgical site infections in patients.24 Enlisting Support through Engagement and Participation A number of people interviewed are very effective in enlisting the support of others in the organization who do not report to them. Their success depends on their ability to engage others in supporting their goals, as summarized in Table 4.2. Table 4.2  Examples of approaches to enlisting support and engaging others Person

Responsible for

Approaches and techniques

Craig Iverson, MA

Lean process improvement

Recognizes that people doing the work have the best ideas and knowledge about how to improve things. Asks clerical staff for their honest input. Ensured their recommendations were listened to and acted on by senior managers in the organization.25

Joanie Gergen, CRCR

Revenue cycle management that required implementation of a policy change in patient fee collections

Enlisted support of peers in clinical and nonclinical positions. Conducted focus groups to elicit input from the people who collect fees directly from clients. Presented training proposal to senior management. Gained approval and trained everyone in the organization. Project earned high praise from state auditors, who remarked on the organization’s exceptional efforts and results.26

Cathie McLean, LPC, CAC III

Clinical quality improvement planning and completion

Offers choices rather than imposing orders. Drives project selection by asking, “What’s the one thing we can make the most difference in?” Clinical teams are motivated to work on the goals that they selected because they align meaningfully with their values.27

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Building Positive Relationships Kathleen Winsor-Games (2018) explains that in the context of your professional success factors, “Your relationships depend on your ability to influence and collaborate with others. Earn trust by communicating transparently and honoring commitments. Cultivate active listening skills. Too few of us feel truly heard in our daily lives. This means interrupting less often and hearing the other person out, rather than planning what to say next.”28 As illustrated in the previous section, you can develop your influence without imposing directive control on the people you need to lead. When people feel that you respect them, value them, listen to them, and you show that you care about their ideas, they are more likely to cooperate with you and support you, whether or not you have any direct control over them. Your success depends on the cooperation of others to get things done. You cannot do it all alone. Sometimes you need resources and information that you do not have and need to get from others, and sometimes it is the other way around. It is easier to ask for what you need from someone whom you have already built a relationship with by getting to know them and helping them by providing what they need. How to Build Your Business Relationships Shari Harley (2013) offers straightforward advice about this. “If you want to take charge of your career, invest time in your business relationships. Ask questions about what people need, want, and are expecting from you.”29 As we discussed in Chapter 3, this is an important part of your plan for your first 30/60/90 days in your new role; you should make a point of building these relationships within your first 30 days. My 30/60/90-day plan focused heavily on meeting others and asking about their needs. This established positive working relationships that were extremely helpful and valuable in my ongoing work throughout the organization. Focusing on others and asking about their needs is a good way to start building relationships. One way to start is to seek out new colleagues, introduce yourself and your new role, and invest some time in getting to know them, asking them questions, and sharing some information about yourself.



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Suggested Avenues to Initiate Work Relationships 1. Invite coworkers to coffee or lunch for casual conversation and to get to know each other. This is an opportunity to share information about each of your backgrounds and work goals to discover ways to align and support each other at work. And as you begin to share some information about your personal life and interests, you will start to connect on a friendly interpersonal basis. Perhaps you will discover some shared experiences or interests outside of work that you can enjoy talking about together such as regions you have lived in, activities you enjoy, sports and activities of family members, books, movies and other media and entertainment, hobbies, places you like to go to, and other forms of recreation. 2. Allocate some time for lunch or brief breaks in common areas where others congregate. Initiate conversations with others, ask questions about them, their work, and other interests. It is easy to start with casual comments that others can agree to, such as, “It’s nice to find fresh, hot coffee on a cold day!” Then move to a brief introduction, “Hi, I’m Taylor Gray. What’s your name?” and progress to asking about where they work and what they do in the organization before you offer information about yourself. Then you could comment or ask a question about what they’re working on: “It’s great to meet someone in Information Services! What’s it been like for you to support the new health record system conversion?” Now you may have the start of a relationship in another department that you can continue to build on. 3. Join work groups and committees that include people from outside your own team and department. To direct your time wisely, select those where you have a genuine interest and can learn or contribute your experience and skills in useful ways. 4. Join company-sponsored teams or recreational activities. Use ­recreational facilities where you will encounter people from other areas. Learn their names and roles and build up conversations and interaction with them. 5. Volunteer to handle activities that require your special expertise and offer your help to people who work in other departments and levels.

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For example, you might offer to conduct training in areas of needed skill development for others, write and edit articles for company newsletters, or organize visible events and campaigns for your organization. 6. Represent your team or organization in external activities to build relationships in your local and professional community. Building and Deepening Relationships As people get to know you, they become more interested in spending time with you and helping you access resources to meet your goals. And it is important to follow through and deliver what you commit to do, as we explained in the previous chapter. When you deliver to others what they need and expect from you, that establishes their trust in you and their willingness to provide what you need from them. People learn that they can count on you to support them and deliver what you promise, and they become willing to support you when you need it. Often, what people need from you is information and cooperation that helps them accomplish goals and fulfill their commitments. As we and our colleagues build collaboration and cooperation across our teams and functional areas of responsibility, we contribute to the success of the overall organization. Nurture Relationships with Gratitude You also need to nurture your associations with others to obtain their support. Gratitude and willingness to reciprocate are important. Cherie S­ ohnen-Moe (2016) reminds us, “One of the most essential habits to develop is prompt and gracious acknowledgment of all the people who support you. A little recognition goes a long way!”30 Matthew Kelly (2007) refers to appreciation as “the strongest currency in the corporate culture . . . . Nobody likes to feel that they are being taken for granted—that just builds resentment.”31

Examples of Actions and Conversations That Build Relationships 1. Recognize others by asking for their help or advice. “I heard you’ve been successful at getting different people to work smoothly



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together. I’m starting a new project where people seem to have very different goals. Do you have any suggestions for leading them toward closer alignment?” 2. Offer your help to others. “I heard you say you’d be away next month when you’re scheduled to teach a CPR class. I’m certified to do that, so if you need someone to cover it for you, I’d be happy to do it.” Even if your colleague has it covered, she’ll likely appreciate your offer and might seek you out next time. 3. Compliment someone on her accomplishment or performance. “I really enjoyed your presentation today. I learned a lot from all your research and experience with trauma-informed care! Thank you for sharing it with us, it will really help us provide better treatment to our patients.” Of course, with any compliment, make sure it is sincere and be specific enough that people understand what you are recognizing them for. 4. Show appreciation by thanking someone, sincerely and specifically. “Thank you for supporting me in today’s meeting. Your speaking up helped others understand why I believe this issue is so important. I really appreciate your help.” 5. Invite someone to join your committee or participate in a work group. “I’ve been assigned to lead the critical incident committee. I’d really value your objective perspective on difficult problems; would you be willing to serve on this committee with me?” 6. Offer to share resources and information. “I have a copy of that book you wanted to look at. Would you like to borrow it?” “It sounds like there was some confusion about how the committee reached its decision last week. I was in the meeting where the data was presented. Would you like to see a copy of it?” Of course, you will protect sensitive information and share only what you are authorized to disclose. Benefits of Relationships around the Organization There are many good reasons for developing relationships with others in your organization. It is good to build give-and-take collaboration so you can get and offer help to others when needed. Do not be overly dependent

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on your boss. It is not necessary for you to direct every question to your boss when there are peers and others who can help you. Your other relationships can increase your value in helping your team when you learn about other resources and activities elsewhere in the organization. This can be true of other community activities you participate in outside your own organization. For example, when I was volunteering with another local agency, I found out that agency was moving part of its operations to a new facility. I shared this nonconfidential but “insider” information with my boss promptly, who quickly approached his community collaborators to secure the soon-to-be-vacated space for our program. This helped our team expand our reach to serve more people, which made my boss and his boss very happy. Other opportunities may come up that position you to work with and get to know others in the organization. I remember when I was a new therapist and our team was allocated two slots to attend the annual statewide mental health conference. I expected to defer to the more senior members on my team, but to my surprise, no one else wanted to take week-end time to attend the conference, so I gratefully accepted the opportunity to not only learn new skills, but to get to know other people in my organization. I attended an event organized by our CEO to gather members of our organization, and there I met our medical director for the first time. He turned out to be the hiring manager several months later of the next position I interviewed for and was selected to fill. I did not normally have day-to-day contact with the medical director, but I had another opportunity to work with him in a training exercise dyad in a seminar I was allowed to attend because I had completed my regular work with clients and was caught up on my documentation and record-keeping. Having met and established some dialogue with him beforehand made me much more comfortable and confident in explaining in my interview how I could contribute in the new role I was applying for and filled. Another opportunity arose when our CEO actively sought participation from staff at different levels to help improve organizational morale. I had not had the opportunity to interact with him directly before that point but when he put out an open invitation in our companywide



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newsletter for interested people to join his morale committee, I ran it by my supervisor. She respected my work and supported my professional growth and interests, so with her support, I joined the committee and established positive working relationships with not only the CEO but with several others who would become valuable collaborators and teammates in my next position in administration. Besides making your work time more pleasant and enjoyable, there are many benefits in cultivating working relationships all around your organization or community. Your boss might move to other responsibilities or out of the organization altogether and you might find yourself moved to another team or role and reporting to someone else. Make sure you and your work are known and viewed favorably by others who can support your efforts and advocate for you when situations change (as they inevitably will in the fast-paced world of health care delivery!) This is one of the reasons it is important for you to develop a solid positive reputation for aligning with organizational values, making valuable contributions toward the organization’s goals, and providing good customer service to other teams.

Up, Down, and All Around for Your Successful Transition to Administration In this chapter, we have focused a lot on relationships, which are at the core of most of the skills we have covered in this first volume, Management Skills for Clinicians, Volume I: Making the Transition from Patient Care to Health Care Administration. Your world has expanded from a focus on individual patients you have cared for 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 this first volume helped you understand the special features of managing in health care settings, take charge to lead your team, manage the performance of those who report to you, involve others in planning, organize your activities, influence others around you to collaborate with you, and build relationships with the people you manage, along with your boss and others around you. Now you are prepared to manage in all directions to lead other professionals and administer many of the necessary activities that keep health care organizations running smoothly.

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As you grow and develop in your management role, you will encounter continuing opportunities to advance the skills you worked on in this first volume and to learn new specific business skills we will cover in the second volume, Management Skills for Clinicians, Volume II: Advancing Your Skills to Thrive in Administration. There you will learn more about enhancing your relationships and 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 enhances performance and motivation to sustain your success as a health care manager.

Chapter Summary and Key Points In this chapter, we looked at the dynamics of interacting with people at various levels relative to your position. We examined the importance of working well with your boss to understand her expectations, along with ways for you to align with her goals. We considered the importance of influence and relationships to build collaboration and offered approaches that can help you motivate others to want to work with you, especially when you have no authority over them to require them to support you. We looked at the benefits of building relationships in different areas of your organization and we suggested some actions and conversations to help you connect with others and begin to build relationships with them. We conclude this chapter with an explanation of the core role of relationships throughout all your activities as you become an effective health care manager and continue to develop in your professional career. We summarized the skills you learned in this first volume, Management Skills for Clinicians, Volume I: Making the Transition from Patient Care to Health



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Care Administration. We offered a preview of what you will see in the second volume, Management Skills for Clinicians, Volume II: Advancing Your Skills to Thrive in Administration, where you will advance your relationship skills and learn additional business skills to help you thrive in administering your management responsibilities. Key Points: 1. You need to build relationships at work. You cannot do it all alone. 2. Relationships are at the core of most of the skills you need to learn to become a successful health care manager. 3. Much of the time, others are not required to do what you want them to do. You need to learn to influence them to want to collaborate with you. 4. Your relationship with your boss is particularly important because he has power that shapes your success; he can bestow or deny rewards to you based on his perceptions of your performance. 5. Demonstrate loyalty to your boss and respect the chain of command to keep your boss informed of what he needs to know. 6. Find out what information your boss wants to receive from you and how to present it so it is clear and useful to her. 7. To be successful in meeting your boss’s expectations, you need to make sure you know what her expectations are and that your goals align with hers. Organize your activities to discuss with your boss and get her feedback. 8. Seek out people in other areas of your organization and get to know them. 9. Your relationships throughout the organization are beneficial to your success as a manager. 10. Do not be overly dependent on your boss. It is not necessary for you to direct every question to your boss when there are peers and others who can help you. 11. Your other relationships can increase your value in helping your team when you learn about other resources and activities elsewhere in the organization. 12. Enlist others to support you by inviting their participation in activities that are interesting and valuable to them.

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13. Remember to show appreciation for what others do well and express gratitude when others help and support you. 14. As you grow and develop in your management role, you will encounter continuing opportunities to advance the skills you worked on in this first volume and to learn new specific business skills, which we will cover in the second volume, Management Skills for Clinicians, Volume II: Advancing Your Skills to Thrive in Administration.

Learning Activities for This Chapter 1. Consider the relationships you have and those you still need to build, along with what is expected between you and others in these relationships. Filling in the tables below can identify gaps in what you need to know about your organization and your position in it, along with external channels you need to be aware of. Think about other information or clarity you need to answer these questions, where will you find it, and who can help you get it. a. Let us start with the relationships you need to manage upward, with your boss and your boss’s boss, as identified in Table 4.3. b. Who else are you accountable to, sideways (Table 4.4)? In other words, who are you required to deliver results to—who depends Table 4.3  Relationships to manage upward a. What have I already established in this relationship?

a. Expectations for me to deliver or support this person(s)/area(s).

b. What are the gaps? What do I still need to know and build?

b. How will my success be measured in meeting expectations?

Who do I report to? Name and position:

a.

a.

b.

b.

My boss reports to (name and position):

a.

a.

b.

b.

Relationship



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Table 4.4  Relationships to manage sideways a. What have I already established in this relationship?

a. Expectations for me to deliver or support this person(s)/area(s)

b. What are the gaps? What do I still need to know and build?

b. How will my success be measured in meeting expectations?

Internally, I’m accountable to:

a.

a.

b.

b.

Externally, I’m accountable to:

a.

a.

b.

b.

Others I’m accountable to:

a.

a.

b.

b.

Relationship

on you for information, coordination, project completion, problem resolution, and other areas? Consider both internal teams, external organizations, and others. What do these people or groups expect from you and your team, and how will you track your performance in meeting their expectations? c. What expectations for performance and behavior do you have for the people who report to you (Table 4.5)? How have you communicated these? Add a row for each key position and a few people in it who report to you, then complete the cells for each one. Table 4.5  Expectations for people who report to you a. What have I a. Expectations for already established performance and in this relationship? behavior

Relationship Position that reports to me, person(s) in this position:

b. What do I need to build and communicate?

b. How will I measure their success in meeting the expectations I set?

a.

a.

b.

b.

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2. Review the subsection, “Examples of Actions and Conversations That Build Relationships” in the last section of this chapter on building positive relationships. Who could you reach out to apply some of these suggestions to show appreciation, gratitude, or a desire to collaborate? What could you say sincerely and specifically to communicate clearly to the other person what you noticed and recognize him for? 3. What opportunities do you see in your workplace to build and strengthen your working relationships with others (Table 4.6)? Consider the settings and activities where you could interact with these groups of people, how you could initiate connections and strengthen relationships. For example, you probably already interact with your peers in team meetings, and you might encounter your boss and others at that level in larger company meetings or by participating in special projects. What could you say or do that builds connections through these encounters and follow-up activities? Table 4.6  Building and strengthening relationships

Groups

Setting or activity

Actions to initiate connections, build and strengthen relationships

a. Colleagues, peer-level people you work with. b. Your boss and others at that level and above. c. Your team members who report to you. d. Others whom you don’t supervise directly, but you require their support and contributions for the success of things you are responsible for. e. Others outside your organization whose projects or activities can help you build valuable relationships and skills.

4. How would you adjust the format and contents of Table 4.1, the ­Example Table of Activities to Track and Review that we showed earlier in this chapter, to organize your key activities, progress, and results to present them effectively to your boss?

APPENDIX A

Interview Participants and Selected Highlights Participants Participants are listed here with their roles and organizations at the time of each interview. As this work has been developing over several years, some have moved to other organizations or positions since their earlier interviews. 1. Emily Anderson, LPC (Licensed Professional Counselor), LAC ­(Licensed Addictions Counselor), Assistant Program Manager in Residential Services, Mental Health Center of Denver (2015). 2. Julie Artigliere, PhD, CCC/SLP, Speech Therapist (2017). 3. Jackie Attlesey-Pries, MS, RN, CENP, Chief Nursing Officer, ­Boulder Community Health (2017). 4. David Bachrach, MBA, FACMPE/LFACHE, The Physician Executive’s Coach (2018). 5. Barbara Becker, LPC, PhD, JD, Director of Mental Health First Aid Colorado (2017). 6. Kenneth T. Bellian, MD, MBA, Co-founder of AI Health and GettingHome, Chief of Clinical Strategy at Jensen + Partners, former Chief of Clinical Operations at Denver Health (2017). 7. Mary Ellen Benson, Vice President of Healthcare Development and Transformation, Aspen Pointe (2017). 8. Paul Bretz, D.Min, LCSW, MHSA, Executive Director, Centus Counseling, and Behavioral Health Surveyor, Joint Commission (2017).

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9. Lucille Campbell, MA, Former Director of Health Initiatives at the Center for African American Health, CEO of AffinityWithLucille Consulting (2017). 10. Annette Cannon, PhD, MA, RN, MSN, Nursing Faculty and Simulation Coordinator, Platt College School of Nursing (2015, 2017). 11. Billy Carestio, BSN, RN, Director of Nursing, Mental Health Partners (2017). 12. Dixie Casford, LPC (Licensed Professional Counselor), MBA, Vice President of Acute Care, Mental Health Partners (2017). 13. Carl Clark, MD, Chief Executive Officer, Mental Health Center of Denver (2018). 14. Beth Coleman, MS, Director of Payer Strategies, Mental Health Center of Denver (2018). 15. Amanda Daniel, Licensed Professional Counselor (LPC), Program Manager in Child & Family Services, Mental Health Center of Denver (2015). 16. Gene Dankbar, MBA, MS, Senior Principal Health Systems Engineer, Assistant Professor of Health Care Systems Engineering. Mayo Clinic (2017). 17. Louise Delgado, LPC, CPHQ (Certified Practitioner of Healthcare Quality), Chief Executive Officer of Solvista Health (2017). 18. David Dobrzykowski, PhD, Associate Professor, Director of Supply Chain Management Institute, Bowling Green State University, Academic Scholar, Cornell Institute for Healthy Futures. President of the College of Healthcare Operations Management of the Production and Operations Management Society (2018). 19. David C. Dugdale, MD, FACP, Medical Director of Care Management and Population Health, Professor of Medicine, University of Washington Medicine (2017). 20. Ric Durity, VP of Development, Mental Health Center of Denver (2018). 21. George Eliopulos, MD, Assistant Medical Director, Mental Health Partners (2017). 22. Bruce Fehn, CPA. Senior VP of Finance and Administration, Rutgers University (retired) (2018).



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23. Joanie Gergen, CRCR (Certified Revenue Cycle Representative), Revenue Cycle Director, Mental Health Partners (2017). 24. Tina Howard, LiCSW (Licensed Clinical Social Worker), Therapist in private practice, Northampton, MA (2017). 25. Craig Iverson, MA, Director of Training and Process Improvement, Mental Health Center of Denver (2017). 26. Jami Kovach, PhD, Associate Professor of Project Management Program and Director of Lean Six Sigma Professional Training Program at the University of Houston (2018). 27. Darcy Jaffe, MN, ARNP, PMH-CNS-BC, NE-BC, FACHE, Chief Nursing Officer and Sr. Associate Administrator, Harborview Medical Center (2017). 28. Jennifer Leosz, LCSW (Licensed Clinical Social Worker), Vice President of Clinic Services. Mental Health Partners (2017). 29. Marilyn Thomas Leist, EdD, Executive Director (retired), Ingleside at King Farm (2018). 30. Valerie Lipetz, MD, Chief Medical Officer of Ambulatory Services and Population Health, Boulder Community Health (2017). 31. Christina Loetscher-Whetstone, BSN, RN, Director of Nursing, Mental Health Center of Denver (2015). 32. Don Maestas, LPC, LAC, MBA, Chief Program Officer, Tennyson Center for Children (2017). 33. Jim Markham, MA, former director of wilderness therapy in a therapeutic boarding school (2018). 34. Kay Martin, LCSW, Chief Operations Officer at Solvista Health (2018). 35. Cathie McLean, LPC, CACIII, Director of Quality Improvement & Assurance, Mental Health Center of Denver (2018). 36. Fred Michel, MD, Chief Medical Officer, Mental Health Partners (2017). 37. Bill Milnor, MA, Vice President of Business Processes, Mental Health Center of Denver (2017). 38. Kristi Mock, LCSW, Chief Operating Officer, Mental Health Center of Denver (2017). 39. Jim Monk, DDS, Dentist with Dental Aid of Boulder County (2017).

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40. Cynthia Nelson, CPA, Controller, Mental Health Center of Denver (2018). 41. Margie Nelson, MSHS, Assistant Vice President of Patient Experience, HCA (2017). 42. Chris Noonan, Vistage International Group Chair (2017). 43. Mary Peelen, Director of Health Information Management Systems and HIPAA Privacy Officer, Mental Health Center of Denver (2018). 44. Donald Penning, MD, MS, Director of Anesthesiology and Director of Perioperative Services, Denver Health (2015). 45. Kelly Phillips-Henry, PsyD, MBA, CEO, Mental Health Partners (2018). 46. Lisa Potter, MSHA, MBA, Chief Financial Officer, Asera (2018). 47. Chris Radigan, LCSW (Licensed Clinical Social Worker), Program Manager in Adult Recovery Services, Mental Health Center of Denver (2015). 48. Elvira Ramos, Vice President of Programs and Inclusive Leadership, Community Foundation of Boulder County (2017) 49. Craig Robbins, MD, MPH, Medical Director of Evidence Based Practice, Kaiser Permanente (2015). 50. Vicki Rodgers, MA, LPC, Chief Operating Officer, Mental Health Partners (2018). 51. Jean Rosmarin, PhD, Licensed Psychologist, Program Manager, Mental Health Partners (2017). 52. Trista Ross, PharmD, Pharmacy Site Manager, Genoa (2017). 53. Jesús Sanchez, PhD, Licensed Psychologist, Wardenburg Health Services (2017). 54. Kendall Sauer, MA, Evaluation Manager, Colorado Office of Behavioral Health (2017). 55. Darla Schueth, RN, BSN, MBA, Chief Executive Officer and President of TRU Community Care (retired) (2018). 56. Preston Simmons, MPH, DSc, FACHE, Chief Operations ­Officer & Interim CEO, Providence Health (2017). 57. Erica Snow, MS, MPA, Portfolio Director, Colorado Health Foundation (2017). 58. Roy Starks, MA, CRC, Vice President of Rehabilitation Services and Reaching Recovery, Mental Health Center of Denver (2018). 59. Michael Sullivan, MD, MBA, Chief Transformation Officer, Covenant Healthcare (2017).



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60. Ginny Trierweiler, PhD, President and Principal at Mastering Mission (2015–2017). 61. Jeff Tucker, JD, Vice President of Human Resources, Mental Health Center of Denver (2018). 62. Michael Ward, MD, PhD, Emergency Physician and Assistant Professor of Emergency Medicine, Vanderbilt University Medical Center (2018). 63. Nancy Wollen, BSN, RN, MBA, Senior Vice President at Kaiser Permanente (2015). 64. Jeff Zayach, MS, Executive Director, Public Health of Boulder County (2017).

Highlights of Selected Interviews Brief highlights of a few of the interviews are included here to illustrate some of the themes. A complete alphabetical listing of everyone who was interviewed, or contributed through other conversations with the author, is available in the preceding section. Those who are not mentioned in the succeeding sections have been included in other chapters and notes throughout the book. How People Moved into Manager Roles Emily Anderson, for example, let her supervisor know that she wanted to move into a management role. While working as an individual residential counselor, she completed a graduate program for her master’s degree in counseling and completed further requirements. She passed the required examination and completed many hours of experience to earn further credentials as a Licensed Professional Counselor, and additional credentialing as a Licensed Addiction Counselor. So, she was prepared to step into the next level of challenge as an assistant program manager. She has continued to demonstrate her value that positioned her for further promotion into a program manager position the following year.1 Another example is Kristi Mock, LCSW, Chief Operating Officer of the Mental Health Center of Denver, who started 34 years ago as a therapist. Her continual progression to higher levels and broader scopes of responsibility began with volunteering to cover interim management

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responsibilities when there was a gap. “Be that person leadership can count on,” she advises, and “volunteer to do lots of different things to expand viewpoints and perspectives, while continuing to be a high performer in your primary responsibilities.”2 DC Dugdale, MD, started in the National Service Medical Corps, working in a prison in an underserved area. When the director there left, Dr. Dugdale got the position.3 Several hospital MDs, such as Dr. Michael Sullivan of Covenant Health4 and Dr. Valerie Lipetz of Boulder Community Health, were intentional in seeking out leadership opportunities by volunteering to serve on committees that offered experience and visibility. Dr. Lipetz volunteered to represent her organization on the board of directors of another community health organization that collaborates with hers.5 Craig Robbins, MD, of Kaiser Permanente ran for elected positions to represent his organization to gain leadership experience and visibility.6 Interacting with senior leaders in the organization provided many of our interviewees with opportunities for getting noticed and showing what they could do. Early in the nursing career of Nancy Wollen, RN, MBA, she made a point of showing up for administrative meetings fully prepared to present a professional image and contribute as a confident leader. As part of her preparation, she allowed time to change from scrubs to a business suit.7 Serving in Their Professions and Communities Everyone who spoke with me cares deeply about the people and communities they serve and the teams of people they lead. Paul Bretz continues to focus on the well-being of the people he and his organizations serve throughout his successful career leading and serving in a variety of settings.8 Darla Schueth, BSN, RN, MBA, started in a home health agency and moved into management early in her career when the agency needed a supervisor of the home health nurses.9 Later in her career, she rose to levels of Executive Director, then President, and CEO of hospice organizations, and became a recognized national expert in her field. Kay Martin, LCSW, agrees that we need to step up, which includes doing the things no one else wants to do, to get them done, and contribute value within and outside your organization.10



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Jeff Zayach, MS, Executive Director of Boulder County Public Health, emphasized the importance of building relationships both internally and externally, especially to impact the health of the overall community and populations served by his organization. He values learning and development of the staff in his organization and enjoys bringing back what he learns, from graduate education in Organizational Leadership and other forums, to train others. In his organization, there is strong commitment to coaching and developing all employees to succeed in their roles. There is meaningful investment in ongoing training and education to develop skills and prepare people to progress in their careers.11 Strengths-Based Work Cultures Many of our interviewees have taken self-assessments that helped them understand their strengths and work styles so they could build their strengths and help develop their staff members. A particularly enthusiastic learner and voracious reader of management and leadership books, Bill Milnor, MA, of Mental Health Center of Denver (MHCD), mentors many new and progressing managers.12 He became a champion of his organization’s culture of well-being with assessment of each employee’s top five strengths with accompanying coaching, training, and dissemination of shared language to utilize and develop such strengths. Carl Clark, MD, CEO of MHCD, explains more in Volume II, Chapter 2, how the tenets of well-being have evolved and strengthen the organization’s enduring employee engagement.13 Ric Durity, Vice President of Development at MHCD, explained the value of considering diversity and inclusiveness in the culture in his workplace because different generations of workers have different experiences and expectations at work.14 Quality Management for Collaboration and Empowerment Jami Kovach, PhD, Associate Professor, and a number of others, have taught many clinical teams to apply tools from quality and Six Sigma to design and implement systems that improved organizational operations and results.15 Louise Delgado, LPC, CPHQ, Chief Executive Officer of Solvista Health, collaborated with colleagues in earning their certifications

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as professionals in health care quality. Twenty years later, after rising to the position of CEO, she willingly participated in quality management activities by helping with quality audits while other staff members were away on leave.16 Jackie Attlesey-Pries, MN, Chief Nursing Officer at Boulder Community Health, has led many training sessions in quality and patient safety to empower everyone in the organization to improve the quality of care for patients.17 Applying Skills in New Ways Margie Nelson, MSHS, applies her experience in Patient Experience to train others in the organization, and has coached physicians on ways to help patients through difficult procedures when they are scared or uncomfortable.18 Mary Peelen, Director of Health Information Systems Management at the Mental Health Center of Denver, worked as a Certified Nursing Assistant early in her career. She learned many quality management skills while working in home health care, and later developed an interest in organizing records while working in hospitals. When she moved to a different health care segment and was learning the operational challenges in not-for-profit community mental health, she realized, “I have a lot of skills and I can help!”19 Kelly Phillips-Henry, PsyD, MBA, learned valuable skills in her Air Force service, which taught her how to lead with confidence and organize her priorities and plans for action.20 Jim Markham, MA, stepped into a new challenge of managing people who had more experience than he did in a wilderness therapy program, and worked on establishing credibility before implementing cultural changes and applying his training in music therapy.21 Kendall Sauer, MA, Evaluation Manager at the Office of Behavioral Health at Colorado Department of Human Services, learned about working with multicultural and refugee populations in her program in International Disaster Psychology. She applied such principles to run effective meetings by ensuring everyone had an opportunity to be heard and to contribute.22 Vicki Rodgers, LPC, CHC, CPHC, Chief Operating and Integrity Officer at Mental Health Partners, applied valuable training in customer



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service and financial management from her early banking career to her later work in health care.23 Marilyn Thomas Leist managed software projects and quality in a large technology company, where she learned the value of managing people, which helped her later to successfully lead teams of people from varied disciplines including nursing and other health care professionals in senior living communities.24 Barbara Becker, LPC, JD, PhD, Director of Mental Health First Aid Colorado, has applied her broad and deep experience in a number of areas in her clinical, judicial, and managerial careers. She advises that new managers, especially someone coming to the position from outside the organization, be patient, get the lay of the land before making changes, gain experience, learn from peers, and consult with your peer group for support. She found it helpful to utilize workshops and other resources for needed content knowledge—for example, progressive discipline for performance issues and getting to know other administrative departments (especially Human Resources) ahead of time before their help is needed to solve problems.25 Mentoring and Peer-Level Support Darcy Jaffe, MN, FACHE, Chief Nursing Officer at Harborview Medical Center, values the guidance and support mentors can provide. She encourages newly hired clinicians to shadow her to understand the scope of what health care leaders do in their work.26 Mary Ellen Benson at Aspen Pointe was trained clinically and worked as a physical therapist earlier in her career. She remembers helpful advice she received when she became interim Chief Executive Officer in a rehabilitation hospital. She reported to the corporation’s Senior Vice President, who told her, “You got here because of who you are. This is a people business. Be who you are and lead from within.” Later, when she officially rose to fill the CEO position, she obtained valuable help from an external group of women in equivalent positions in other organizations.27 Similarly, Paul Bretz, DDiv, LCSW, MHSA, of Centus Counseling and the Joint Commission for Accreditation of Healthcare Organizations, and Don Maestas, LPC, LAC, MBA, of Tennyson Center for Children, found groups of peer leaders outside their organizations to be very helpful

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in their development, especially as they progressed into higher-level leadership roles with increasing complexity and fewer internal peer-level colleagues to consult.28,29 Billy Carestio, BSN, RN, Director of Nursing at Mental Health Partners, was fortunate to find a mentor early on when he was still in school. This instructor got to know Billy’s interests and abilities and shared with him her impression about his capabilities and how he could apply them when she declared, “You are a psych nurse!” This helped Billy realize what he believes he was meant to become and to begin to navigate a successful path toward that professional goal.30 George Eliopolus, MD, Assistant Medical Director of Mental Health Partners, expressed appreciation for the “benevolent others,” including people in administrative and other roles in the organization, who helped him succeed as he gained new management responsibilities.31 Fred Michel, MD, Chief Medical Officer at Mental Health Partners, appreciated the help he received from other professionals in Human Resources, Finance, and other areas of administration to understand organizational policies and budgeting issues.32 Communities of resources have been helpful to Tina Howard, ­Licensed Clinical Social Worker in private practice along with work as a school counselor and consultant. She joined an online group of colleagues in her community in western Massachusetts that provides useful peer consultation on both clinical issues and business operations. Workshops with this group helped her master needed skills for running the business aspects of her therapy practice such as billing and insurance payments.33 Applying Knowledge of Business Management Preston Simmons, MHA, DSc in Health Services, FACHE, holds top leadership positions in one of the largest health care systems in the United States. With over 30 years as a health care leader and executive, his wide and varied experience includes planning and building partnerships. He retooled and led a health care system turnaround and its implementation, and redesigned operations funded and administered through Medicaid.34 As another example, David Bachrach, MBA in Healthcare Administration, FACMPE/LFACHE, applies experience he gained as a senior



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executive in several physician-led academic health care organizations, including the University of Michigan Medical School and the University of Texas M.D. Anderson Cancer Center. He developed leadership programs for physicians at several universities and built a coaching practice focused on selecting and developing physician leaders in academic medical centers.35 Before earning his PhD and becoming a university professor, David Dobrzykowski earned an executive MBA and graduate certificate in public health epidemiology. He worked as a health care executive for a number of years, rose to the position of regional CEO and turned around a struggling health care organization before successfully launching three new facilities. Now he teaches health care operations management to clinicians and other business professionals who seek positions as health care managers. He estimates that three-quarters of the students in the health care operations management courses he has taught were trained initially as clinicians, and others wanted to extend their business training to become health care managers. His in-depth understanding of the business issues in health care management contributed to his selection as one of the top 50 health care management professors in 2015 to 2016.36 To provide additional perspectives on the value of strong business management skills, I talked with Elvira Ramos, Vice President of Inclusive Leadership at the Community Foundation of Boulder County, and Erica Snow, MPA, MS, Portfolio Director of the Colorado Health Foundation, who have worked in health care organizations and now influence community foundations’ investments in grant funding by evaluating the effectiveness of health and human service organizations and their leadership teams.37,38 Beth Coleman, MS, Director of Payer Strategies at the Mental Health Center of Denver, negotiates contracts with payers and leads the strategic development of value-based service delivery packages with clinical colleagues.39 Financial management expertise in tracking and managing revenue and expenses was provided in interviews with Bruce Fehn, CPA, who was Senior Vice President of Finance and Administration at Rutgers University, which merged with University of Medicine and Dentistry of New Jersey;40 Cynthia Nelson, CPA, Controller at the Mental Health

144

APPENDIX A

Center of Denver;41 and Lisa Potter, MS, MBA, Chief Financial Officer at ­AseraCare.42 Lucille Campbell worked initially in other roles and industries where she learned business and analytical skills that she applied later in leading health and human service organizations such as her role as Director of Health Initiatives at the Center for African American Health.43 Building Confidence in Your Leadership Abilities Billy Carestio, BSN, RN, Director of Nursing at Mental Health Partners, started his management path during his hospital work as a nurse when his nurse manager chose him to be a charge nurse: a working, expert nurse on the floor, who handled the schedule of nurses. He continued to take on extra development and duties, and became a Crisis Prevention & ­Intervention Instructor, earned additional nursing certifications (AMNCC and PMH-RN), attended his organization’s Diamond Leadership Academy, and participated in monthly coaching sessions to enhance his effectiveness in emotional regulation, goal setting, how to express himself, and how to listen.44 Emily Anderson, LPC, mentioned the importance of showing confidence, even when you do not know all the answers, and how earning credentials helps especially when managing people who are older or more experienced.45 Kelly Phillips-Henry, PsyD, MBA, explains why confidence was important in her early service in the Air Force. “It’s about your bearing, that is, composure and posture. When you’re thirty years old and others are fifty with more experience, you have to show confidence that you know what you’re talking about.” As an example, when people are nervous, they say “um.” It detracts from their message and makes them appear unconfident. Instead, learn to pause, the silence can be powerful. This takes practice.46 George Eliopulos, MD, Assistant Medical Director at Mental Health Partners, agrees that, “Doctors are trained to be in charge: ‘The buck stops here.’” He is energized by clinical work and has always been concerned with “what impacts my practice and patients.” He observed that a challenge for doctors working with administrative requirements is, “We don’t always understand the ‘why.’”47

APPENDIX B

Meeting Agenda Form Table B1 Meeting agenda form Meeting Facilitator Recorder Members Present Members Absent Guests

Topic Meeting opener Review of action items Patient safety course Training priorities for next quarter Review action items and owners Meeting feedback and wrap-up

Key points

Decisions and action items (to fill in with notes as meeting progresses)

Topic owner

Start time

APPENDIX C

Example of an SBAR Mental Health Partners SBAR Proposal for Walk-Through Process Reviews Developed by Linda LaGanga, September 30, 2016 SITUATION: We are rapidly developing new policies and implementing new procedures to align our day-to-day operations with the current and evolving landscape of health care. Even with thorough design and communications among multidisciplinary teams within our organization, we find situations where new processes did not work out as intended and our customers (clients, community members, and other stakeholders) may run into difficulties. In responding to problems or complaints from external customers, we have found breakdowns in the process and points where we could make things run more smoothly. In retrospect, we have seen that if we had tested processes from external and unfamiliar perspectives, or rehearsed scripts for new interactions with customers, there were opportunities to prevent or correct problems before customers had negative experiences. BACKGROUND: Methodology has been developed in the service management discipline and applied successfully to help service organizations elicit feedback from customers and others unfamiliar with new processes. The purpose is to evaluate the service experience from a customer’s perspective because customers often become aware of cues (or their absence) that the employees and managers might overlook.

148

APPENDIX C

Description of Walk-Through Audit from Fitzsimmons, Fitzsimmons, and Bordoloi (2013): Purpose: Conduct a systematic assessment of the entire customer service experience from beginning to end. Focus: Measure customer perceptions of the effectiveness of each stage of the service delivery process. Process: 1. Create a flowchart of the service delivery process from the customer’s perspective. 2. Design, test, and administer questionnaires to a sample of customers, management personnel, and/or customers at benchmark organizations. 3. Walk through the real or proposed process with the group above and apply the survey to assess their actual experience with the process, and elicit their reactions to possible problem points. 4. Summarize and analyze survey results with emphasis on low ratings relative to benchmark firms and gaps between management and customers. 5. Determine deficiencies and implement improvements. 6. Repeat for ongoing improvement.

ASSESSMENT: “Walk-Through Audit” methodology, developed by Fitzsimmons and Maurer (1991) for restaurant service performance, could be used as a foundation for us to proactively review new processes and policy decisions and improve them before releasing them to our customers. This practice, applied successfully in other service industries, appears promising in helping us improve satisfaction of internal and external customers, reduce complaints from clients and other stakeholders, and improve efficiency and effectiveness of our processes. RECOMMENDATIONS: Adapt “Walk-Through Audit” methodology to apply to our own “Walk-Through Process Reviews” for new and



APPENDIX C

149

modified processes with high impact on clients and other stakeholders. Utilize our Quality and Process Improvement teams to consult with process owners on conducting Walk-Through Process Reviews in areas such as Service Redesign, appointment setting, and other points of service access. Use Walk-Through Process Reviews to coordinate with—not ­replace—other tools such as Client Experience Survey and Design for Six Sigma. This would be another tool in our kit for considering process effects on customers. Coordinate with Client Experience surveys to identify opportunities for service improvement and test new service concepts prior to implementation. Involve Client and Family Advisory Council to participate in Walk-Through Process Review design and execution and to recommend additional participation.

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

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

Chapter 1 1. Paul Bretz, D. Divinity, LCSW, MHSA, Executive Director of Centus Counseling and Site Examiner for Joint Commission for Accreditation of Healthcare Organizations, in an interview with the author, October 12, 2017. 2. Preston Simmons, DSc, MHA, FACHE, CEO (Interim, Western ­Washington Market) and Chief Operating and Administrative Officer of Providence Health and Services, in an interview with the author, August 4, 2017. 3. Kenneth T. Bellian, MD, MBA, Co-founder of AI Health and GettingHome, Chief of Clinical Strategy at Jensen + Partners, former Chief of Clinical Operations at Denver Health in an interview with the author, ­December 21, 2017. 4. Vonderembse and Dobrzykowski (2016, pp. 42–44). 5. Annette Cannon, RN, MSN, PhD, Instructor at Platt College of Nursing, in conversation with the author, June 9, 2015. 6. Billy Carestio, BSN, RN, Director of Nursing, Mental Health Partners, in an interview with the author, June 26, 2017. 7. Christina Loetscher-Whetstone, BSN, RN, Director of Nursing, Mental Health Center of Denver, in an interview with the author, March 26, 2015. 8. Dixie Casford, LPC, MBA, Vice President of Acute Care, Mental Health Partners, in an interview with the author, October 27, 2017. 9. Jen Leosz, LCSW, Vice President of Clinic Care, Mental Health Partners, in an interview with the author, October 27, 2017. 10. Chris Radigan, LCSW, Program Manager of Adult Outpatient ­Services, Mental Health Center of Denver, in an interview with the author, March 23, 2015.

152 NOTES

11. George Eliopulos, MD, Assistant Medical Director at Mental Health Partners, in an interview with the author, June 30, 2017. 12. Michael Ward, MD, Assistant Medical Director at Mental Health Partners, in a conversation with the author, May 3, 2018. 13. Kenneth T. Bellian, MD, MBA, Co-founder of AI Health and GettingHome, Chief of Clinical Strategy at Jensen + Partners, former Chief of Clinical Operations at Denver Health in an interview with the author, ­December 21, 2017. 14. Kristi Mock, LCSW, Chief Operating Officer at the Mental Health Center of Denver, in an interview with the author, October 27, 2017. 15. Donald Penning, MD, Director of Anesthesiology and Perioperative Services at Denver Health, in an interview with the author, June 16, 2015. 16. Jesús Sanchez, PhD, Licensed Clinical Psychologist, Wardenburg Health Services, in an interview with the author, October 17, 2017. 17. Nancy Wollen, RN, BSN, MBA, Senior Vice President and Chief Operating Officer of Kaiser Permanente, Colorado, in an interview with the author, August 28, 2015. 18. Lucille Johnson Campbell, MA, Former Director of Health Initiatives at the Center for African American Health, CEO of Affinity With Lucille Consulting, in an interview with the author, November 8, 2017. 19. Kelly Phillips-Henry, PsyD, MBA, CEO of Mental Health Partners, in an interview with the author, February 12, 2018. 20. Bill Milnor, MA, Vice President of Business Processes, Mental Health Center of Denver, in an interview with the author, October 12, 2017. 21. Mary Ellen Benson, VP of Healthcare Development and Transformation, Aspen Pointe, in an interview with the author, August 10, 2017. 22. Amanda Daniel, LPC, Program Manager, Mental Health Center of Denver, in an interview with the author, March 31, 2015. 23. Don Maestas, MA, LPC, MBA, Chief Program Officer of Tennyson Center for Children, in an interview with the author, November 2, 2017. 24. Darcy Jaffe, MN, FACHE, Chief Nursing Officer, Harborview Medical Center, in an interview with the author, September 18, 2017. 25. Jim Monk, DDS, Dentist at Dental Aid of Boulder County, retired from private dental practice, in an interview with the author, October 30, 2017. 26. Julie Artigliere, PhD, CCC/SLP, President at Center for Vocal Health, Inc., in an interview with the author, October 30, 2017. 27. Tina Howard, LICSW, Licensed Social Worker in Private Practice, in a conversation with the author, November 12, 2017. 28. Jean Rosmarin, PhD, Program Manager, Mental Health Partners, in an interview with the author, October 17, 2017.

NOTES 153

29. Barbara Becker, LPC, PhD, JD, Director of Mental Health First Aid ­Colorado, in an interview with the author, November 11, 2017. 30. Dixie Casford, LPC, MBA, Vice President of Acute Care, Mental Health Partners, in an interview with the author, October 20, 2017. 31. 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. 32. Joanie Gergen, CRCR (Certified Revenue Cycle Representative), Revenue Cycle Director, Mental Health Partners, in an interview with the author, December 28, 2017. 33. Jami Kovach, PhD, Associate Professor of Project Management Program and Director of Lean Six Sigma Professional Training Program at the ­University of Houston, in an interview with the author, January 3, 2018. 34. Chris Noonan, Vistage International Group Chair, in a conversation with the author, December 20, 2017. 35. Kenneth T. Bellian, MD, MBA, Co-founder of AI Health and GettingHome, Chief of Clinical Strategy at Jensen + Partners, former Chief of Clinical Operations at Denver Health in an interview with the author, ­December 21, 2017. 36. Preston Simmons, DSc, MHA, FACHE, CEO (Interim, Western ­Washington Market) and Chief Operating and Administrative Officer of Providence Health and Services, in an interview with the author, August 4, 2017. 37. Sohnen-Moe (2016, p. 66). 38. Jeff Zayach, MS, Executive Director, Boulder County Public Health, in an interview with the author, November 30, 2017. 39. Craig Iverson, MA, Director of Training and Process Improvement, Mental Health Center of Denver, in an interview with the author, December 8, 2017.

Chapter 2 1. Ginny Trierweiler, PhD, in e-mail communication with the author, January 25, 2018. 2. Armstrong (2013, p. 28). 3. Horstman (2016, p. X in Introduction). 4. Deming (1986). Published in 1986, this book is considered by many to be a management classic, especially in the field of quality management where it is referred to frequently. Deming’s famous “14 Points for Management” capture his enduring wisdom and strong opinions about how to manage

154 NOTES

5. 6. 7. 8. 9. 10. 11. 12. 13.

14.

15. 16. 17.

18. 19.

20. 21. 22. 23. 24. 25. 26. 27.

organizational processes and systems while leading people effectively to develop them to their full potential. Christina Loetscher-Whetsone, BSN, RN, Director of Nursing, Mental Health Center of Denver, in an interview with the author, March 26, 2015. Armstrong (2013, p. 2). Horstman (2016, p. 166). King (2013, p. 113). Horstman (2016, p. 173). Chris Radigan, LCSW, Program Manager, Mental Health Center of ­Denver, in an interview with the author, March 23, 2015. Jeff Tucker, JD, Vice President of Human Resources at the Mental Health Center of Denver, in an interview with the author on February 1, 2018. Dobson and Dobson (2000, p. 194). D.C. Dugdale, MD, FACP. Medical Director of Care Management and Population Health, University of Washington Medicine, in an interview with the author, October 18, 2017. Elvira Ramos, VP of Programs and Inclusive Leadership, Community Foundation of Boulder County, in an interview with the author, October 24, 2017. Kristi Mock, LCSW, Chief Operating Officer, Mental Health Center of Denver, in an interview with the author, October 27, 2017. Migoya (April 15, 2006). Jennifer Leosz, LCSW, Vice President of Clinic Care, Mental Health Partners, in conversations with the author throughout the course of working together in 2015–2016. Jackie Attlesey-Pries, MS, RN, CENP, Chief Nursing Officer at Boulder Community Health, in an interview with the author, November 10, 2017. Craig Iverson, MA, Director of Training and Process Improvement, Mental Health Center of Denver, in an interview with the author, December 8, 2017. Horstman (2016, pp. 84–92). Dobson and Dobson (2000, p. 73). Amanda Daniel, LPC, Program Manager, Mental Health Center of Denver, in an interview with the author, March 31, 2015. Harley (2013, p. 154). David Bachrach, MBA, MBA, FACMPE/LFACHE, The Physician Executive’s Coach, in an interview with the author, April 19, 2018. Patterson et al. (2012, pp. 204–205). Winsor-Games (July 2, 2017, p. 7K). Harley (2013, pp. 155–6).

NOTES 155

28. Sutton (2010). 29. Michael Ward, MD, PhD, MBA. 2018. Roundtable discussion, “What Happened to My Patient? Patient Outcomes Reporting in the Veterans Health Administration,” College of Healthcare Operations Management Conference, May 3, 2018. 30. Jackie Attlesey-Pries, MN, Chief Nursing Officer at Boulder Community Health, explained in her interview with the author on November 10, 2017, that she taught Just Culture when she was at Mayo Clinic. 31. Darcy Jaffe, MN, FACHE, Chief Nursing Officer, Harborview Medical Center, in an interview with the author, September 18, 2017. 32. Annette Cannon, PhD, MSN, in an interview with the author, October 19, 2017. 33. Frankel et al. (2006, pp. 1690–1709). 34. Darla Schueth, RN, BSN, MBA, CEO and President of TRU Community Care, in an interview with the author on April 4, 2018. 35. Murphy (2017, pp. 191–2). 36. Ibid., p. 193. 37. Lucille Johnson Campbell, MA, in an interview with the author, November 8, 2018. 38. Blanchard and Johnson (2003). 39. Carnegie (1981, pp. 205–43). 40. Billy Carestio, BSN, RN, in an interview with the author, June 26, 2017. 41. Pink (2009). 42. Jen Leosz, LCSW. Vice President of Clinic Care at Mental Health Partners, in an interview with the author, October 20, 2017. 43. Tina Howard, LICSW, in a conversation with the author on May 1, 2018. 44. David Bachrach, MBA, FACMPE/LFACHE in an interview with the author, April 19, 2018. 45. Markle (2000). 46. Hogler (2015, p. 1). 47. U.S. Equal Employment Opportunity Commission (n.d.). 48. Jeff Tucker, JD, Vice President of Human Resources at the Mental Health Center of Denver, in an interview with the author on February 1, 2018. 49. Mader-Clark and Guerin (2016, p. 3). 50. Roy Starks, MA, VP of Rehabilitation Services and Reaching Recovery, Mental Health Center of Denver, in an interview with the author, June 12, 2018. 51. Dixie Casford, MA, LPC, MBA, Vice President of Acute Care Services at Mental Health Partners, in an interview with the author, October 20, 2017.

156 NOTES

Chapter 3 1. Levinson and Cooper (2015, pp. 64–66). 2. Hurman (July 31, 2012). For more details and resources, see Watkins (2013). 3. The “Clinical Site Needs Analysis” was a methodology the author adapted from earlier work in the computer software industry. As a member of strategic selling teams, she and colleagues developed this consultative approach initially as a “Site Needs Analysis” framework for visiting manufacturing sites of prospective customers, observing work processes, and asking questions about the organization’s problems and needs. From this, solutions were developed with software demonstrations that were presented to the customer’s managerial decision-making team. This approach strengthened the consultative partnering relationship between seller and buyer and helped close new business for software licenses and consulting. 4. Lencioni (2004). 5. Cloud (2010, p. 114). 6. Kenneth T. Bellian, MD, MBA, Cofounder of AI Health and GettingHome, Chief of Clinical Strategy at Jensen + Partners, former Chief of Clinical Operations at Denver Health, in an interview with the author, December 21, 2017. 7. Carl Clark, MD, CEO of Mental Health Center of Denver, began to apply this approach in 2006 after MHCD’s executive team participated in “Pathways to Leadership” training, by Verus Global, which was later disseminated throughout the organization. The approach of opening meetings with questions became widely adopted in meetings throughout the organization. 8. Harley (2013). 9. Institute for Healthcare Improvement (IHI) (2017). According to the online tools and description at this IHI website, this technique was initially developed by Michael Leonard, MD, Physician Leader for Patient Safety, along with colleagues Doug Bonacum and Suzanne Graham at Kaiser Permanente of Colorado (Evergreen, CO, USA) as a communication tool between members of the health care team about a patient’s condition. The tool was adapted from the U.S. Navy. The SBAR technique has been implemented widely at health systems such as Kaiser Permanente. 10. Patterson et al. (2012, pp. 177–8). 11. Drucker (January 1967a). 12. Drucker (1967b, p. 148). 13. Armstrong (2013, p. 21). 14. Patterson et al. (2012, p. 187). 15. Ibid.

NOTES 157

16. 17. 18. 19.

20. 21.

22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

Armstrong (2013, p. 28). Marilyn Thomas Leist, EdD, in an interview with the author, April 4, 2018. Murphy (December 5, 2014). Kenneth T. Bellian, MD, MBA, Co-founder of AI Health and GettingHome, Chief of Clinical Strategy at Jensen + Partners, former Chief of Clinical Operations at Denver Health in an interview with the author, December 21, 2017. Dobson and Dobson (2000, p. 20). 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. Drucker (1967, p. 51). Dobson and Dobson (2000, pp. 138–9). Douglass and Douglass (1993, p. 4). Ibid., p. 11. Doran (1981, pp. 35–36). Drucker (1967, pp. 25–51). Lakein (1973). Covert and Satterson (2009, p. 307). Covey (1989, pp. 148–50). Ibid., pp. 151–4. Tracy (n.d.). Allen (2001, pp. 13–16). Ibid., p. 43. Ibid., pp. 46–47.

Chapter 4 1. Barta and Barwise (April 2017, pp. 3–4). 2. Strayer (2017). 3. Erica Snow, MPA, MS, Portfolio Director, The Colorado Health Foundation, in an interview with the author, October 27, 2017. 4. Dobson and Dobson (2000, Introduction, p. xii). 5. Ibid., p. xiii. 6. Ibid., p. 105. 7. Harley (2013, p. 65). 8. Dobson and Dobson (2000, pp. 106–107). 9. Ibid., p. 107. 10. Ibid., pp. 3–4. 11. Ibid., p. 2. 12. Harley (2013, p. 67).

158 NOTES

13. 14. 15. 16. 17. 18. 19.

20. 21.

22. 23.

24.

25. 26. 27. 28. 29. 30. 31.

Ibid. Carnegie (1981, p. 33). Covert and Sattersten (2009). Jackie Attlesey-Pries, MS, RN, CENP, Chief Nursing Officer at Boulder Community Health, in an interview with the author, November 10, 2017. Armstrong (2013, pp. 22–23). Chris Noonan, Vistage Chair, in a meeting with a coaching group, ­December 20, 2018. Mary Peelen, Director of Health Information Systems Management at the Mental Health Center of Denver, in an interview with the author, January 10, 2018. Trista Ross, PharmD, Pharmacy Site Manager at Genoa, in an interview with the author, November 4, 2017. Preston Simmons, DSc, MHA, FACHE, CEO (Interim, Western Washington Market) and Chief Operating and Administrative Officer of Providence Health and Services, in an interview with the author, August 4, 2017. Michael Sullivan, MD, Chief Transformation Officer at Covenant Healthcare, in an interview with the author, November 7, 2017. Michael Ward, MD, PhD, Emergency Physician and Assistant Professor of Emergency Medicine, Vanderbilt University Medical Center, in a conversation with the author, May 3, 2018. Kenneth T. Bellian, MD, MBA, Co-founder of AI Health and GettingHome, Chief of Clinical Strategy at Jensen + Partners, former Chief of Clinical Operations at Denver Health in an interview with the author, December 21, 2017. Craig Iverson, MA, Director of Training and Process Improvement, Mental Health Center of Denver, in an interview with the author, December 8, 2017. Joanie Gergen, CRCR, Director of Revenue Cycle at Mental Health Partners, in an interview with the author, December 28, 2017. Cathie McLean, LPC, CAC III, Director of Quality Improvement, Mental Health Center of Denver, in an interview with the author, January 16, 2018. Winsor-Games (January 7, 2018, p. 5K). Harley (2013, p. 5). Sohnen-Moe (2016, p. 84). Kelly (2007, p. 74).

Appendix A 1. Emily Anderson, LPC, LAC, Program Manager, Mental Health Center of Denver, in an interview with the author, March 30, 2015.

NOTES 159

2. Kristi Mock, LCSW, Chief Operating Officer at the Mental Health Center of Denver, in an interview with the author, October 27, 2017. 3. David C. Dugdale, MD, Medical Director of Care Management and Population Health, Professor of Medicine, University of Washington Medicine, in an interview with the author, October 27, 2017. 4. Michael Sullivan, MD, Chief Transformation Officer at Covenant Health, in an interview with the author, November 7, 2017. 5. Valerie Lipetz, MD, Chief Medical Officer of Ambulatory Services and Population Health at Boulder Community Health, in an interview with the author, October 13, 2017. 6. Craig Robbins, MD, Medical Director of Evidence Based Practice, Kaiser Permanente Care Management Institute, in an interview with the author, August 28, 2015. 7. Nancy Wollen, RN, MBA, Senior Vice President and Chief Operating ­Officer, Kaiser Permanente of Colorado, in an interview with the author, August 28, 2015. 8. Paul Bretz, D.Divinity, LCSW, MHSA, Executive Director of Centus Counseling and Site Examiner for Joint Commission for Accreditation of Healthcare Organizations, in an interview with the author, October 12, 2017. 9. Darla Schueth, RN, MBA, President and CEO of TRU Community Care, in an interview with the author, April 4, 2018. 10. Kay Martin, LCSW, Chief Operating Officer, Solvista Health, in an interview with the author, June 1, 2018. 11. Jeff Zayach, MS, Executive Director, Boulder County Public Health, in an interview with the author, November 30, 2017. 12. Bill Milnor, MA, Vice President of Business Processes, Mental Health Center of Denver, in an interview with the author, October 12, 2017. 13. Carl Clark, MD, CEO of the Mental Health Center of Denver, in an interview with the author, January 16, 2018. 14. Ric Durity, Vice President of Development, Mental Health Center of ­Denver, in a conversation with the author, February 1, 2018. 15. Jami Kovach, PhD, Associate Professor of Project Management Program and Director of Lean Six Sigma Professional Training Program at the ­University of Houston, in an interview with the author, January 3, 2018. 16. Louise Delgado, LPC, CPHQ, Chief Executive Officer of Solvista Health, in e-mail exchanges with the author, December 7–8, 2017. 17. Jackie Attlesey-Pries, MS, RN, CENP, Chief Nursing Officer at Boulder Community Health, in an interview with the author, November 10, 2017. 18. Margie Nelson, MSHA, AVP of Patient Experience at HCA, in an interview with the author, October 25, 2017.

160 NOTES

19. Mary Peelen, Director of Health Information Systems Management and HIPAA Privacy Officer, Mental Health Center of Denver, in an interview with the author, January 10, 2018. 20. Kelly Phillips-Henry, PsyD, MBA, CEO of Mental Health Partners, in an interview with the author, February 12, 2018. 21. Jim Markham, MA, former director of a wilderness program in a therapeutic boarding school, in a conversation with the author, January 21, 2018. 22. Kendall Sauer, MA, Evaluation Manager, Office of Behavioral Health at Colorado Department of Human Services, in an interview with the author, November 15, 2017. 23. Vicki Rodgers, MS, LPC, CHC, CHPC, Chief Operating and Integrity Officer, Mental Health Partners, in an interview with the author, January 31, 2018. 24. Marilyn Thomas Leist, EdD, Executive Director of Ingleside at King Farm Retirement Community, in a conversation with the author, February 24, 2018. 25. Barbara Becker, LPC, JD, PhD, Director of Mental Health First Aid ­Colorado, in an interview with the author, November 7, 2018. 26. Darcy Jaffe, MN, FACHE, Chief Nursing Officer, Harborview Medical Center, in an interview with the author, September 18, 2017. 27. Mary Ellen Benson, Vice President of Healthcare Development and Transformation, Aspen Pointe, in an interview with the author, August 10, 2017. 28. Paul Bretz, D.Divinity, LCSW, MHSA, Executive Director of Centus Counseling and Site Examiner for Joint Commission for Accreditation of Healthcare Organizations, in an interview with the author, October 12, 2017. 29. Don Maestas, LPC, LAC, MBA, Chief Program Officer, Tennyson Center for Children, in an interview with the author, November 2, 2017. 30. Billy Carestio, BSN, RN, Director of Nursing at Mental Health Partners, in an interview with the author, June 26, 2017. 31. George Eliopulos, MD, Assistant Medical Director, Mental Health Partners, in an interview with the author, June 30, 2017. 32. Fred Michel, MD, Chief Medical Officer at Mental Health Partners, in an interview with the author, June 30, 2017. 33. Tina Howard, LICSW, therapist in private practice in Northampton, MA, in a conversation with the author, November 12, 2017. 34. Preston Simmons, DSc, MHA, FACHE, CEO (Interim, Western ­Washington Market) and Chief Operating and Administrative Officer of Providence Health and Services, in an interview with the author, August 4, 2017. 35. David Bachrach, MBA, Fellow of the American College of Medical Practice Executives, Lifetime Fellow of the American College of Healthcare Executives, Principal, The Physician Executive’s Coach, Inc., in an interview with the author, April 19, 2018.

NOTES 161

36. David Dobrzykowski, PhD, Associate Professor at Bowling Green State University, in an interview with the author, April 23, 2018. 37. Elvira Ramos, Vice President of Programs and Inclusive Leadership, Community Foundation of Boulder County, in an interview with the author, October 24, 2017. 38. Erica Snow, MPA, MS, Portfolio Director, The Colorado Health Foundation, in an interview with the author, October 27, 2017. 39. Beth Coleman, MS, Director of Payer Strategies, Mental Health Center of Denver, in an interview with the author, January 16, 2018. 40. Bruce Fehn, CPA, Senior Vice President of Finance and Administration, Rutgers University, in an interview with the author, June 4, 2018. 41. Cynthia Nelson, CPA, Controller, Mental Health Center of Denver, in an interview with the author, January 16, 2018. 42. Lisa Potter, MBA, MS, Chief Financial Officer of AseraCare, in an interview with the author, June 4, 2018. 43. Lucille Johnson Campbell, MA, Former Director of Health Initiatives at the Center for African American Health, CEO of AffinityWithLucille Consulting, in an interview with the author, November 8, 2017. 44. Billy Carestio, BSN, RN, Director of Nursing, Mental Health Partners, in an interview with the author, June 26, 2017. 45. Emily Anderson, LPC, LAC, Assistant Program Manager at the Mental Health Center of Denver, in an interview with the author, March 30, 2015. 46. Kelly Phillips-Henry, PsyD, MBA, Chief Operating Officer, Mental Health Partners, in an interview with the author, February 12, 2018. 47. George Eliopulos, MD, Assistant Medical Director, Mental Health Partners, in an interview with the author, June 30, 2017.

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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 Accomplishments, tracking of, 53 Accountability interviews and, 12 managers and, 36–42 fair and just culture, 37 psychological safety in work environment, 38 quality improvement, reporting and tracking for, 38–39 Administrators. See Managers Administrative meetings, 72 Behaviors coaching and, 48 expectation for, 19, 39 for managers, critical, 22 Business relationships, 122–125 Coaching, 48–53 description of, 48 for employee development, 51–53 ideal approaches, 49 importance of, 48–49 with motivational factors, 50 role in, 50 timing of, 50–51 Constructive engagement, interviews and, 9 Credibility and responsibility, interviews and, 7–8 Decision making, 81–89 command, 85–86 consensus, 88–89 consulting and, 86–87 dialogue and, 81–82 effectiveness of, 82 expectations and, 82–85 importance of other people decisions, 89 time and, 85 voting and, 88

Delegating responsibility, manager and, 22–25 Disciplines nonclinical, 12–13 progressive, 57–58 time management and, 100 Expectations decision making and, 82–85 importance of, 90 interviews and, 7 negotiations and, 90–91 performance, 39, 42–47. See also Performance expectations Expectations management model, 40–42 Health care management. See also Management skills caring of people and work, 3 delivery, complicated drivers of, 4 description of, 2 efficiency, change for, 3–4 manager and. See Manager standards and, 4 Honesty, 89–90 Influence, importance of, 118–121 command-and-control approaches, 120 communication and, 120–121 enlisting support, 121 leadership and, 118–120 matrixed environment, 120 Interviews questions, 6–7 themes for, 7–13 accountability, 12 constructive engagement, 9 credibility and responsibility, 7–8 expectations, 7

170

INDEX

Interviews (Continued ) experiences and perspectives, applications of, 10 helping others, 9–10 leadership, 8–9 mentoring, 11 nonclinical disciplines, 12–13 other resources, learning from, 10–12 relationships, 10–11 systems and teams, 13 for variety of perspectives, 4–6 Leadership, interviews and, 8–9 Management skills, motivation for, 2 Managers, 1–6, 8–15, 20–32, 48, 93, 137–138 accountability and, 36–42 fair and just culture, 37 psychological safety in work environment, 38 quality improvement, reporting and tracking for, 38–39 boss, relationships with, 109–118 activities, organization of, 115–116 chain of command, 111 checklist for alignment, 114–115 goals and needs, 113–114 loyalty problems, 111–113 negotiation, 117–118 reporting, 109–110 support and value, 110 coaching and. See Coaching decision making and. See Decision making delegating responsibility, 22–25 guidelines, 23–24 helping others, 24–25 time management, 25 expectations, 32–36 behavior, steps in managing, 39 communications, 34–36 decision-making latitude, 35 description of, 32–33 management model, 40–42 performance, 39, 42–47

understanding, 34 importance of, 20–22 meetings and. See Meetings planning and description, 65–66 guidelines, 66–68 proactiveness and, 68–69 power and trust, 25–32 acknowledging others, 30 commitment, 28 effectiveness of power, 26 escalating disrespect and, 30–32 foundation, building of, 25–26 gaining trust, 32 professional relationship, 28–29 resistance management, 29 values and, 26–28 relationships with boss, 109–118 value of, 108–109 responsibilities of, 21–22 time management and, 92–101 consolidated tracking, 99–100 description of, 92 discipline and consistency, 100 goals, importance of, 93–94 SMART approach, 93–94 techniques, 94–101 Meetings, 69–79 administrative, 72 agenda, example of, 78–79, 145 purpose of, 72 SBAR tool for, 79–81 strategic, 72 structure of, 73–77 agenda items and updates, 77 brief check-in or question, 75–76 follow-up, 76 introduction and focal point, 74–75 roles and responsibilities, 73–74 wrap-up, 77 types of, 71 Mentor, 13–15 looking for others, 14 peer-level help, 14–15 professional development and, 15 Nonclinical disciplines, 12–13

INDEX 171

Performance expectations, 39, 42–47 feedback and, 46–47 performance scale and, 44–45 standards and, 44–46 word pictures and, 43–44 Performance problems, 54–59 challenges, 59 conversation and, 55 follow-up in writing, 55–56 planning for improvements and measurements, 57 progress evaluation, 57 progressive discipline, 57–58 suspension and termination, 58 Performance tracking and planning, 53–54 Planning description, 65–66 guidelines, 66–68 proactiveness and, 68–69 Positive discipline program, 58 Positive relationships, building of, 122–127 Power and trust, managerial role and, 25–32

Progressive discipline, 57–58 Psychological safety in work environment, 38 Quality improvement, manager and, 38–39 Relationships benefits of, 125–127 business, 122–125 give-and-take support for, 91 interviews and, 10–11 positive, building of, 122–127 SBAR tool, 79–81, 147–149 SMART approach, 93–94 Strategic meetings, 72 Time management, 92–101 consolidated tracking, 99–100 description of, 92 discipline and consistency, 100 goals, importance of, 93–94 SMART approach, 93–94 techniques, 94–101

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 • • • • •

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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 This book introduces new healthcare managers to the skills they need to transition and succeed in their managerial roles. More experienced managers can benefit, too, from examples and collected insights of other managers who were interviewed and from examples in recent and revisited literature. The author covers both “hard” business skills and “soft” people/organizational skills. We draw from books, articles, examples, and managerial experience of the author and colleagues at different organizational levels and throughout healthcare settings and professions. 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.

Healthcare Management Collection David Dilts and Lawrence Fredendall, Editors

MANAGEMENT SKILLS FOR CLINICIANS, VOLUME I

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