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Case Study: Results with Maximum Change

By Dr. Philip A. Foster

Background A premier interventional pain management and ambulatory surgery center in middle Tennessee focused on helping adults with musculoskeletal or neuropathic conditions regain strength, mobility, and function while avoiding narcotics or major surgery. This highly regulated medical practice (the practice) is headed by an acclaimed physician and leader in the field of interventional pain management.

The practice was in process of becoming an accredited surgery center. With the expansion, the stakeholders were seeking additional surgeons to join the practice. During disclosure it was determined the practice was losing on average $110,000 a month in revenue and this would limit interest by investing physicians to join.

Diagnosis We focused on four main areas of concern: Front-office mismanagement, workplace conflict, disengagement of the stakeholder/leader, and back-office mismanagement.

Front-office (intake) mismanagement included customer service, scheduling, purchasing, intake (pre-authorizations), pre-billing, co-payment, proper paperwork and compliance.

Customer Service: Reception is the first experience patients have with the practice. Going to a doctor, specifically for chronic pain is not a pleasant experience to have. It is important that reception work to ease tensions and to be a friendly reassuring face of the practice. At the time of the review, the practice had a front desk staff that was lacking in the area of customer service. Some areas of concern include: long wait-times for patients, improper interactions with patients, phone etiquette was rough and sometimes even costic. Some patients were turned away because they arrived without the proper documentation or referrals.

Compliance issues: HIPAA violations were observed. Specifically the positioning of computer monitors and conversations overheard from the waiting room.

Scheduling conflicts: Patients sat in the waiting area for extended periods of time and on occasion some may have been turned away altogether. No front office manager or practice manager who can delegate work and maintain workflow. Very little accountability of time, resources, scheduling, etc on a regular basis.

Expenses: Reception oversaw the purchasing and expenses within the organization. There was no inventory control over oversight and expenses were out of control.

Workplace conflict is not uncommon as it typically involves differences of opinion, style, or approach that are not easily resolved. In the case of this practice, there were layers of conflict. There were conflicts between co-workers as well as conflicts between the stakeholders and employees. The greatest level of workplace conflict in the practice was between the stakeholders and employees in that there were proper ways to do the work and then there was the way the employees wanted to do the work.

Disengaged leadership is a challenge that many organizations face today. What we know about leadership is that it is a participation sport. An engaged leader is about being visible, present, and connected with the employees. Engagement requires strategy and the ability for a leader to recognize their personality and how that plays out in the office setting and among their followers. Disengagement of leadership does not necessarily note a lack of skills or ability.

Leadership engagement takes a lot of time an energy – something many leaders feel takes away from their core responsibilities. In the case of this practice – engagement of the physician requires time that the doctor feels is better spent with patients.

Back-office: Billing issues. Medical billing is in constant fluctuation and is based on a complex set of variables. The billing department was missing opportunities to bill and thereby left a great deal of money outstanding.

Treatment Plan To begin the process, we conducted several days of in-person observations over a one month period. Some of the observations were done without the knowledge of the staff. The first day of observations, Dr. Foster arrived and sat in the waiting area to casually observe the interaction between staff and patients. On another occasion staff was directly observed. One observation was made in secret. Dr. Foster entered from the back door and sat in a back office down the hallway from reception so that he could audibly observe what was going on in the office.

Dr. Foster met directly with a compliance consultant and the physician/stakeholder of the practice to get input from both parties as to the problems at hand. The compliance consultant was spot on in their observation. The physician focused concerns on what they believed the issues were. Physician felt as if their position within the organization was taken for granted. Physician felts as if the staff was running the show and not him.

An organizational culture assessment was conducted to determine the culture of the organization. The assessment was conducted by use of a questionnaire which requires individuals to respond to six questions. The purpose of the OCAI is to assess six key dimensions of your organization’s culture. Each of the six key dimensions has four alternatives and two columns for each alternative marked now and preferred which indicates how we think it should be in five years in order to be successful as an organization. The OCAI is based on a theoretical model known as the Competitive Values Framework which is used to interpret a wide variety of organizational phenomena such as the organizations core values, assumptions, interpretations, and approaches that characterize the organization. Overall, the survey results indicate: Respondents would like to continue to develop sense of a team. Continued training, team-building and coaching is recommended.

Respondents would prefer less adaptability, flexibility, and creativity. Organization must determine the level of adhocracy desired and develop plans to train and equip the staff in areas where uncertainty, ambiguity, and information overload is possible.

Respondents would prefer a greater focus internally and less externally. Appropriate balance between external and internal focus is required. Given that the organization relies on referrals and relationships external to the organization. A fitting policy and procedure for handing external interaction is recommended.

Respondents desire greater emphasis on hierarchy. Developing policies, procedures, and clear lines of authority and duties would be helpful to the members of the organization.

What was revealed Insurance calls by reception should not be conducted during busy times of the day. Insurance calls should be conducted by someone who will not be continually interrupted.

For HIPAA compliance, front desk computer screen should be positioned so that it cannot be seen by anyone standing at the reception window.

Pre-screening of patients should be conducted via a checklist and that no patient should be given an appointment without proper paperwork submitted. Specifically, referrals and pre-authorizations from insurance should be completed prior to patient arrival as to limit the patients stay in reception waiting.

Pain patients should not be left waiting for a doctor because the doctor is stuck speaking with a drug representative. Drug rep visits should be handled by the practice administrator and any specific meetings required of the doctor should be set at “non-busy” times of the day.

Patients seem to wait a long time – practice should track check in time against wait time.

There is a strong need for weekly intense coaching and mentoring on customer service, time management and even practical computer and office skills.

Front office should have a day-to-day office manager or practice manager that can delegate work and maintain workflow. There appears to be very little accountability of time, resources, scheduling, etc on a regular basis.

Job descriptions should be developed and tied heavily to performance. Such performance measures should be: patient wait time, efficiencies, demeanor, and number of compliments or complaints – just to name a few. Currently raises and bonuses in general are not tied to any such performance metrics.

Practice should have front office staff that is cross-trained in the event of vacation, sick day, etc.

Numerous complaints from referring colleagues. Such complaints can be tied to performance. It would be helpful to poll referring agencies at least once a year asking one or two simple questions to make sure that we are hitting the mark on customer service, etc.

Tracking wait time and scheduling are keys to the overall performance of the practice. The practice is losing money due to inefficiencies in use of physicians time, scheduling and wait times.

Bonuses should not be an expectation of any position – however, if bonuses are to continue they should only be tied to performance as based on the positions job description and performance ratings.

Results Based on observations, discussions with the stakeholders and the organizational culture assessment, we developed an intense coaching plan for the staff as well as the practice leadership. Weekly coaching for employees was focused on workflow, time management and customer service.

Ultimately, It was noted that the position and the practice outgrew one of the staff members capabilities. This particular staff member had been with the practice for many years. After intensive coaching and little improvement, the staff member was ultimately released with a generous severance package.

At our recommendation, two staff trainings were conducted over a one year period. The first training was focused on Customer Service and all staff members with the exception of the physician were in attendance. The second training, held after several changes in staffing, was team building. Again all staff were present with the exception of the physician. The team building process would have been much more powerful if the stakeholders had been present.

After training, coaching and changes in staff, practice went from a loss of $110,000 a month to a 45% increase a month in revenue within 7 weeks. Additionally, expenses went down by 18% with the recommended changes.

For more information on Maximum Change Coaching and Consulting, please visit our website at

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