A System is the Solution

by William D. Esteb

There are only two types of management problems I've ever encountered in my in-office consultations in the United States and Canada: personality problems and communication problems. These are the underlying causes of virtually every "problem" challenging office growth, patient compliance, or other nonclinical issues.

And while personality transplants aren't likely to be perfected, the real opportunity to make significant practice enhancements lies in the ability to improve office communications. As with all communications, it is the responsibility of the sender to make sure the receiver has properly received, decoded, and understood the message.

The good news is that communication skills are not innate. They can be learned. Like the ability to speak, construct a logical argument, shake hands, or like dozens of other ways we communicate, better communication skills can be learned. Impaired communication is the root of a host of so-called "management" problems:

• In an attempt to control the staff or the inability to see its long term pay off, the doctor neglects to create a procedure manual. The result is a staff forced to decipher the doctor's intentions soley from his or her behavior. Without mind reading skills they remain in constant fear of making a mistake and losing their job.

• Collections suffer because the staff doesn't know how far to push or how far they can go and be backed up by the doctor. Can they deny care to patients whose account balance has reached $100, $200, or $500 without payment? Where is the line? The result is a wishy-washy approach to collections that undermines the staff's ability to collect what is legitimately due.

• You're positioning the patient for a neutral lateral cervical X-ray and he asks, "Now, how much radiation will I be getting?" You lie, saying that the exposure is similar to sitting in front of a color TV for several hours, spending a day at the beach, or some other blatantly inaccurate example. And you hope you don't get caught.

• Re-examinations don't get done because there isn't a consistently administered scheduling procedure. The result is a patient who starts feeling better and leaves the practice before complete healing is accomplished for whom there will not be a post X-ray taken to confirm that your technique truly makes structural changes.

• When needing to hire a new staff person, the procedure for doing so is re-invented each time. What did we do last time? What questions do we ask the candidates? How do we train the new person? Without a plan, staff turnover and the resulting seat-of-the-pants training send the practice into a nose dive as the procedure is invented again and again.

• Patient education becomes spotty or nonexistent because it's too complicated, too difficult, or doesn't instantly seem worth the effort. The result is patients who get symptomatic relief, yet don't understand what chiropractic is and refer to their treatment as "getting their back cracked" and receiving "shock treatments."

These dysfunctional office procedures and many others are the result of dysfunctional communications. It's the "can't-you-read-my-mind?" school of office management. It's "management by brushfire." The doctor's attention is directed to the hottest fire (problem). I call this dancing. The room darkens, the mirrored ball starts turning, and the baying saxophones moan what we hope will be a most convincing tune to sell, keep, prevent, or solve any issue the staff or patients present. Not only is this situational approach to practice stressful, it sabotages patients and staff and reduces your capacity to grow and make the greatest possible difference in your community.

Michael Gerber, in his book The E-Myth, Why Businesses Don't Work and What to do About it, observes that one of the major obstacles standing in the way of having a successful small business is the lack of a business "system." He suggests it's the difference between working in your business versus working on your business. Most doctors of chiropractic work in their business, constantly inventing procedures, standards, exceptions, and otherwise making the simple process of delivering their healing skills much too complicated for the staff. While it is prudent to be flexible and to be able to respond quickly during periods of change, most offices are too flexible, too accommodating, and too vague. There's too much dancing.

When a business is run without dancing, the effect is profound. Do you think McDonald's invents how much meat to put into each hamburger? Do you think they guess how many tables and chairs to put into their restaurants? How many parking spaces? How long customers should wait? How deep the stainless steel counter top should be? What an employee should say and do? Ever see a "failed" McDonald's restaurant? Of course not. It's all in a procedure manual. Nothing, and I mean nothing, is left to chance.

A McDonald's franchise owner in Berkeley, California had a Viet Nam war protest outside his restaurant in the late 1960s. Demonstrators stormed the restaurant, demanding that the flag in front of the store be lowered to half-mast. After consulting his procedures manual and finding no help, yet unwilling to succumb to the mob pressure, the quick thinking manager had his assistant "accidentally" back over the offending flag pole, making the half-mast request a moot point. Almost 30 years later, you will find this solution and many others collected from civil unrest, natural disasters, foreign objects in food, and others all written up in a concise, organized fashion. No wonder McDonald's can successfully open two new restaurants every day on this planet! Does this make a McDonald's hamburger taste good? That's up to you or your five-year-old with a Happy Meal to decide. But it does make them the most successful fast food company in the world. What else besides a systems approach to business can account for their success?

In chiropractic, you develop a system so you can spend more time doing what you really enjoy and less time managing, administrating, and handling exceptions. A system is the solution. Michael Gerber invites all small business owners to imagine what it would take to franchise their business. Not that you should franchise your practice, but more than any other "advice," thinking in this way can lead you to some solutions that are systematic and innovative.

Start thinking what it would take to teach someone else to have an office just like yours. Not kind of like yours. Exactly like yours. Without you to coach, rule, troubleshoot, provide exceptions, or be a walking procedures manual. Could you do it by simply photocopying your current "hand-me-down" procedures and policy manual alone? If so, then you're probably doing too much dancing and squandering too much time training new staff members.

Reorienting your practice and systemizing it can start by recognizing those areas or procedures in your practice that remain vague, obscure, or don't get done. At a staff meeting, have everyone list occasions when they feel they must dance. You'll probably discover many of these items lack absolute standards by which to judge their successful completion, are overly complicated, or require too much dependence or waiting on others for important information or guidance. If your staff is in the regular habit of saying, "I'll have to check with the doctor," you can be sure Fred Astaire and Ginger Rogers are warming up in the wings!

If all you really want to do is adjust and spend less time "managing," invest in a procedures manual so your staff is accountable to a written set of standards, and not at the mercy of your mood, your unmentioned fears, or your statistics. Put it in writing. Create a written communication tool that will free you up to work on your business, instead of just in it. Unleash the full potential of your staff and free them to contribute in more meaningful ways than guessing your intentions. Remove the ambiguities and vague areas of responsibility. Free up yourself and your staff to concentrate on the much more important aspects of patient care and patient education.

Buy the book
A Patient's Point of View
Originally published in 1992
240 Pages
US $19.95

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