You Can’t Handle the Truth!

“You can’t handle the truth!”

—Col. Nathan Jessup (played by Jack Nicholson in “A Few Good Men”)

An unforgettable moment in a 25+-year-old movie turned that simple sentence into a permanent part of the American language. Hardly a week goes by without someone around us repeating the line, complete with Nicholson’s inflection and emphasis. It didn’t hurt that the line was delivered by one of the best actors ever to appear on the big screen—but the power of the phrase is in its truth. The fact of the matter is that we humans have a difficult time handling some hard truths.

In practice management, the hardest truths that we have to face usually have something to do with accountability.

In practice management, the hardest truths that we have to face—from the senior-most physician to the lowliest file clerk—usually have something to do with accountability. We tend to fear scrutiny. Most of us know that under close examination we will be found wanting—and we can’t stand the shameful feelings that accompany “being caught.”

Intellectually we all know that “no one is perfect,” but our emotions move us to recoil at the thought of our imperfections being revealed to others. But if we really want our medical practices to achieve top-performer status, we’ll have to overcome this common tendency. One of the characteristics of “emotional intelligence” is the ability to manage emotions—to harness the power of emotions (including the negative ones) and use them to achieve our goals. In other words, you can’t necessarily control your emotions, but you can keep them from controlling you.

”Dysfunction Junction”

Dysfunctional medical practices—like dysfunctional individuals—shrink from personal accountability. The most common manifestation of this fear is simply inaction. Physicians, administrators, supervisors, and employees simply don’t get around to addressing substandard performance. When someone needs to be confronted, we tend to put it off in favor of some other “more urgent” activity. The busy manager says, “I know I need to have a heart-to-heart conversation with that staffer, but I can’t seem to find the time.”

The best-run practices have discovered how to overcome the aversion to accountability.

And if the underperformer is a physician or an administrator, the challenge becomes even greater. In 25 years, I have never worked with a medical practice—as an administrator or as a consultant—without at least one “problem child” physician. And I have rarely seen physicians who can look a colleague in the eye and deliver honest criticism. They could complain about it in hushed tones behind my closed office door—but confront the partner? Not too likely.

The best-run practices have discovered how to overcome this aversion to accountability and create a culture of excellence in its place. They have managed to elevate the needs of the patient and the success of the practice above fragile egos and easily hurt feelings. Physicians and staffers accept critiques for the sake of the higher goals they pursue together.

Five Accountability Processes

Ideally, every individual in your medical practice should feel accountable to someone. It won’t really work to wander around shaking hands with a cheery, “How’m I doin’?” like former New York City Mayor Ed Koch. Effective performance improvement requires a structured approach with mutually agreed-upon standards.

“Accountability” implies authority. If you are accountable to someone, that someone has the right to demand a report of what you did, how well or how thoroughly you did it, and why you did it. We don’t have a choice about our accountability to “the boss” (assuming we want to keep our jobs), so when we voluntarily submit to evaluation by someone else (like a customer), we are saying in effect, “You’re the boss. I want to perform up to your standards.”

You can cover most of your practice performance issues with five feedback processes. Two (patient satisfaction surveys and employee evaluations) are fairly common, but the other three are used less often. All of them require careful planning to set up and stubborn diligence to avoid letting them slip into disuse:

• Patient satisfaction surveys: Businesses in every industry understand the importance of “customer satisfaction.” Although we traditionally don’t like to think of patients as “customers,” they are the ones who buy our services (even if they use an insurance company’s money). Dozens of resources exist for the medical practice that wants to collect feedback from patients. A quick Web search will return a couple million “hits”—and hundreds of Google pages with survey templates, examples, and names of companies that offer patient survey services.

• Referring-physician surveys: Your “other customer”—besides patients and their families—are the physicians and other healthcare providers who refer patients to you. The more “specialized” your practice, the more likely you rely on referrals as your business’s lifeblood. Successful surgeons know that patients don’t normally wake up one day and say, “I don’t feel good. I think I need an operation!” True, some elective procedures attract a significant number of self-referrals—even beyond cosmetic and bariatric surgeries. But by far, the majority of surgeries begin with a consultation requested by another provider. Your referring physicians have a huge say in who buys your services. Referring-physician satisfaction surveys have grown in popularity in recent years. You can find many excellent examples on the Web—surveys used by group practices, healthcare systems, and management services companies. Some are designed as paper forms; others can be filled out and submitted online.

• Employee evaluations: We’ve seen a lot of press in recent years about the uselessness of annual employee evaluations. A number of human resources experts who once championed performance appraisals have come out with strong criticism about the whole process. “Everybody hates employee evaluations” has become an accepted axiom of personnel management. But the criticism is not leveled at the concept of providing feedback—it’s about the flawed process. Most HR professionals who want to do away with annual appraisals emphasize that they must be replaced with a different approach. They usually recommend more frequent feedback—perhaps in a weekly one-on-one supervisor employee meeting.

• Manager evaluations: Working for physicians can be a tough gig. As the manager’s “customers,” they are very hard to satisfy. The job itself can be astoundingly complex; and in the end, some doctors have a particular gift for making you think you could have done more. It’s a rare manager who regularly feels “caught up” on everything that needs to be done. Managers are subject to plenty of criticism, but very few have negotiated a clear set of performance standards for evaluating their work objectively. Ironically, those who undergo a periodic evaluation usually don’t have to endure the constant undercurrent of physician complaints.

• Physician evaluations: Large organizations with employed physicians (as opposed to smaller physician-owned practices) have had more success with direct physician evaluations. They usually have an organizational structure that provides “bosses” who can perform such appraisals. It’s a rare medical practice with partners willing to submit to peer evaluation. In a physician-owned group practice, the logical person to conduct doctor evaluations would be the managing partner. (Larger groups with multiple leaders might include it as part of a medical director’s job.) Most practices elect a president periodically, and the best-run practices have an empowered CEO—that is, he or she has authority and responsibility to lead the practice. The group relies on the leader to make financial, operational, and strategic decisions day-to-day—with certain limitations. Major issues must be brought to the governing board for approval.

Cool-headed Agreements

Group practices commonly make the mistake of trying to establish precedent-setting policies and procedures in the middle of a crisis. Consider the dynamics around the boardroom table if the senior-most physician announces, “I want to drop out of the night-call rotation next month, and retire at the end of the year.” Every discussion, every motion, and every vote connected with that request will be personal. How can you make an objective decision? The best time to decide on retirement policies is when no one is considering retirement any time soon. By the same token, you’ll make better decisions regarding evaluation standards, processes, rewards, and penalties when heads are cool. Work on one system at a time, and set your “effective date” far enough in the future that physicians and staff have sufficient time to mentally process the new level of measured accountability. Model your accountability systems on those already in use by successful practices you admire. That helps you avoid accusations of “targeting” individual doctors or staff members and introduces more objectivity in your standards. If others expect this level of performance, it seems more reasonable to demand the same of your own organization. If your practice has successfully avoided internal performance measures, you’ve probably avoided performing at or near your potential. There’s an old axiom that’s often applied to financial benchmarking: “What gets measured gets done.”