A Proud Family Moment

I commend the Navy for using simulation to minimize the consequences of unconscious incompetence and thank everyone in our armed forces not only for their service to our country but also for their dedication to training.

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

For those of you who are not football fans and wondering what the NFL can teach us physicians, please bear with me. I grew up in Buffalo, NY, the son of a busy neurosurgeon whose passions were surgery, golf, and football. To spend time with my father, I took up golf and watched some of the first Bills’ games with him.

Here are three relevant themes for physicians in transition:

1) How a year begins may have little to do with the way it ends; last spring, it was unclear whether we would even have an NFL season; fortunately, Bob Kraft, owner of the New England Patriots, was able to bring owners and players to consensus in a win-win negotiation, despite the recent death of his wife Myra (the source of the MHK on Patriots’ uniforms); we too can emerge from our uncertainty and have a great year by taking action and learning from our outcomes; ACT, LEARN, ADAPT is a great way to deal with the complexity we face; learning is never failure;

2) Teams that start off great may not finish great unless they have contingency plans; the Buffalo Bills led the AFC East with a 5-2 record, beating their arch-rival New England Patriots early in the season, but finished the season 6-10 due to injuries and inadequate adaptation to their opponents’ second-half strategy; we too can develop better contingency plans by talking with friends and colleagues and benefiting from their feedback, the same way that Andrew Carnegie, Thomas Edison, and Harvey Firestone did when they met monthly in a Mastermind Group;

3) Planning and execution are keys to success; coaches put a game plan into writing; writing involves thinking aloud onto paper; then, the players practice it until it becomes second nature; a Harvard study showed that professionals who write down their goals and review them daily are significantly more likely to achieve their goals than people who try to keep them in their heads;  goals must be SMART:

• Specific
• Measurable
• Achievable
• Realistic yet high
• Time delimited

Now that football season is over, my goals are to update my business plan by March 5, 2012 to give me a clearer roadmap for the year and increase my chances of attaining or even exceeding my goals.

Kenneth H. Cohn, MD, MBA, FACS

© 2012, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Introduction

I really enjoyed teaching at this year’s SEAK conference on Non-clinical Careers for Physicians . I started Thursday September 23, teaching the consulting pre-course with Steve Babitsky and Jonathan Cargan.

Two days later, I spoke on Dealing with Disruptive Change: The Power of Transformation:

Transformation reflects a major change in form, function, or nature.  To me, transformation results from overcoming self-limiting beliefs and taking action on stretch goals at the same time.  Transformation is a way to deal with disruptive change proactively rather than feeling that change is done to us rather than by us.

Consulting

A consultant is a professional with specialized knowledge and expertise who assists clients to improve their situations by providing value-added advice.

Good consultants:

• Learn quickly
• Work well with others
• Are responsive to clients’ needs
• Diagnose even the problems that clients don’t tell them about
• Build consensus
• Provide simple, practical solutions

Dr. Lynn Helmer spoke about ways that consultants can add value by:

• Focusing on service and calling clients back within 24 hours
• Being pleasant and not making clients feel stupid with their answers to questions
• Underpromising and overdelivering
• Delivering a fair return on the client’s investment in consulting services, usually 5-10x, focusing on the metrics that matter

The best way to “make the magic happen” is by setting and delivering on SMART goals that are:

• Specific
• Measurable
• Achievable
• Realistic yet high
• Time delimited

How to excel in interviews

Dr. John Ferry encouraged participants to demonstrate performance by telling stories of situations that they have encountered that indicate managerial talent, especially in the areas of removing roadblocks, building trust, and holding people accountable. One way to diffuse tension at a group interview is to greet everyone around the table with a handshake at the beginning and end of the interview. The best way to demonstrate that you want the job is to express genuine enthusiasm.

 Networking

 Lillian Bjorseth defined networking as an active dynamic process that links people in mutually beneficial relationships. We network for advice, information, recommendations, referrals, and support. Rather than say, “I am a doctor,” she recommends describing what you do and the benefit that you provide to others.

 For example, when I am networking with hospital people, I tell them, “I work with disgruntled doctors and hospital leaders to improve clinical and financial performance.” It takes only 15 seconds and gives them more actionable information than my telling them that I am a general surgeon and MBA who writes books on healthcare collaboration.

It takes just 10 seconds for our brains to form a first impression.

Learning how to turn features into benefits is critical to effective networking.

Kenneth H. Cohn, MD, MBA, FACS

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

As summer approaches, and you look for a new book to take with you on vacation, I wholeheartedly recommend the short stories in A Few Small Moments.  But first, a disclosure.  I have known Carol Scott-Conner for years.  She is a fellow surgeon, friend, and a chapter author in my second book Collaborate for Success.  She tells it like it is:

• In Masks,”she was fighting the angel of death…. No one would die that night.  She had looked feral.”
• In Achilles Heel, “Who could argue with perfectionism in a surgeon? …. The OR was indeed stressful for everyone, and most surgeons managed to keep their cool.  There was a clear line that delineated the appropriate response to that stress.  Alix crossed that line, time and time again.”
• In The Notebook, “The thing is I just don’t care anymore.  And that’s really bad.  I’m thinking of getting out of surgery altogether.  I could write poetry, maybe even go back to school.”
  “She was increasingly pulled in three directions…. She spent 50% of her time taking care of patients, 50% of her time teaching and writing, and 50% of her time in meetings- and yes, that added up to more than 100%. There had to be an easier way to make a living.”
• In Passing Storm, “… I was committed to give a talk to a group of high school kids in one of those innumerable small towns that dotted the area.  A female role model.  I had never felt less like one.  Female failure, more like it.”

There are some wonderful pearls passed on, for example:

• In Passing Storm, “I … sat down on the foot of Janice’s bed…. It puts you on the same level as your patients…. It makes you more human…. Besides, it saves your feet.”
• In Clinic Day, ‘”Is there anything I haven’t asked about that you think might be related?’ Silly question, most people probably thought.  But once in a while, you hit pay dirt.”
• In Who Will Catch Me When I Fall,”She could hear the tension in her own voice and willed herself to relax.  Tension in the small resuscitation room was already high.  Adrenalin made people move faster, made them more alert.  Too much, and they made mistakes.  She had to set the tone.”
  “The law says that clothes for children must be flame-proof, but there isn’t any requirement for clothes for adults.  So little old ladies set themselves on fire when they reach over to get the teapot off the gas stove.  Make sure your grandma has an electric stove, and tell her not to wear her shawl, or anything with trailing sleeves, when she goes near it.”

 I especially liked the last chapter, The Making of a Surgeon:
“Surgeons need to be able to make decisions under conditions of incomplete information, and most surgeons crave the immediate gratification of success or failure.  Most surgeons are distinguished by a buoyant optimism and high energy level…. You need to be well organized and to have a lot of energy and a sympathetic spouse”

I hope that you make this book part of your summer must-reads.

Kenneth H. Cohn, MD, MBA, FACS

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

I apologize for the delay in posting.  No excuses, just a learning curve that is taking me longer than expected:  My new book, Getting It Done, publishes June 20, 2011, and I am learning social media skills not taught when I went to medical school.  During residency, a mentor taught me that any job worth doing is worth doing imperfectly at first in order to get better.

I can only imagine what you must be thinking: “I have enough to do; why do I need to learn selling?”  My point is that you are already doing selling in its most basic form any time you ask a patient to sign an informed consent form or ask a nurse to do a task for a patient.  Selling basically is persuasion, and good salespeople are good listeners (p.15), regardless of how stereotypical salespeople abuse the privilege.  One cannot understand what people want unless one learns to listen.  Unlike hearing, listening is an active process that involves:

• Concentrating on the speaker, maintaining comfortable eye contact
• Listening with one’s eyes as well as ears to be mindful of body language
• Opening one’s stance to convey receptivity
• Suspending judgment to maintain objectivity
• Empathizing, trying to put oneself in the speaker’s frame of reference, using summary questions, such as, “Do I understand you to say….,”

How to Sell Anything to Anyone Anytime by Dan Kahle is a great introduction to the selling process.  He clarifies misconceptions and then writes, “Selling is the science of helping people get what they want” (p.21-2).  Asking questions helps people make decisions that result in their exchanging something that they have for something that you offer.  His Five-Step Selling Process involves (p. 25-7):

• Engage the right people, ie those who recognize that they have a problem, are accessible, have resources to invest, want to resolve their problem now, and are people with whom you enjoy working.  We are not talking about being on call, where one has a duty to see and treat patients.
• Make them comfortable with you, understanding that the other party defines comfort and risk, not you.  The greater his or her perception of the risk, the greater must be the relationship to enable someone to take that risk (p.71).  As with elective surgery, patients must feel that you understand and appreciate their concerns in order to lay their lives on the line.
• Find out what they want and appeal to that need.  Succcessful salespeople probe to discover what issues are important, what problems people want to solve, and what they are looking for in a sales experience rather than force products or services on others.
• Craft your presentation to show them how what you are offering gives them what they want.  If you are not successful initially, analyze whether you are offering the wrong solution or talking to the wrong people
• Gain agreement on the next step.  Every interaction has a next step, extending from gaining  prospects’ attention to setting up a conversation to learn more about their needs to crafting a presentation to solve their problems to getting them to commit to action, ie closing the sale.  A “no” is preferable to a “maybe,” so that you can focus your attention on prospects who truly value what you do rather than on people who are stringing you along.

When you feel great about what you do, selling becomes service, leveraging your talents to benefit others  and being paid for your knowledge and experience.  It is an iterative journey which, like learning judgment and technique, is something that any motivated healthcare professional can master.

Please let me know what you think about edgy posts that address the elephant in the room and what you desire to learn in the future.  May all your transitions be learning journeys.

Kenneth H. Cohn, MD, MBA, FACS

© 2011, all rights reserved

Disclosure:

I have a material connection because I received a review copy that I can keep for consideration in preparing to write this content.

I wanted this to be a celebratory post, and in some ways it is, just not the way I planned it.

I returned with my wife to the Canyon Ranch Spa in Lenox, MA, where last year, I learned how to cook fish at high temperature  fearlessly, among other skills.

Zumba Class

This year, I noted that I was the only male in Zumba class and decided to go the front row just behind the instructor, who is shown graciously giving me after-class merengue instruction. 

It was only the second time that I had attended Zumba class, but I felt relaxed and in the moment.  I like to think of it as action being the hack saw that breaks the prison bars of fear, as I discussed in my last blog post, Building a Culture of Ownership.

I think that part of vacation (in addition to getting exercise and eating great food) is doing something new and being fearless.  Leonard Bernstein reputedly said, “If you are going to fall off a ladder, it might as well be the top rung.”

After the fall

Three days later, I slipped on the ice in front of my house, taking the garbage cans from the street.  I sprained my ankle and fractured my wrist.  All I remember is hearing a dog bark across the street as my legs went out from under me.

It is humbling to reflect on how a second can change one’s life.  At the same time, I am proud of all that I have learned to do with my left hand in less than a week, from eating and toothbrushing to starting my car.

Some times, we do not know what we are capable of until we are challenged in the moment.  These experiences have an unexpected way of reminding us of what we have and keep us from complacency.  As I allow more time in the morning to shower and dress, I think of the sacrifices of our veterans who do not have the use of limbs and how they and their families cope.  It makes me grateful for what I have and (most of the time) keeps me in the present instead of reliving the experience and wondering “What if …” or worrying about the implications of wrist stiffness on my ability to provide locum tenens surgical coverage.

It helped me a day after my accident to be able to help a fellow physician in transition to a new post clarify his new boss’s expectations and focus on the top three priorities.  After we hung up, I thought to myself, “At least I can do telementoring.”  Perhaps at times when we are feeling down on ourselves, we should smile and complete the “At least I can …” sentence.

Kenneth H. Cohn, MD, MBA, FACS

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

In All Hands on Deck, a CEO takes over a company in distress and finds Walt Disney waiting for him in a limousine. They head to The Magic Kingdom and view business legends like Henry Ford, Ray Kroc, Mary Kay Ash, and Jim Burke interacting with colleagues. The CEO tells his staff that they have lost touch with their founding values, adopts a bold new strategy to rebuild the culture, and despite feeling like he should have negotiated combat pay as he listens to employees and customers vent their frustrations, he succeeds in turning the company around.

Once you get past the premise, this is a great book. I especially liked the insights regarding fear (89-91):

• Fear is a reaction; courage is a decision
• Cliques and silos indicate a fear-filled workplace
• Action is the hacksaw that cuts through the prison bars of fear
• Make fear your ally by letting it catalyze you to action instead of allowing it to paralyze you into inaction

He called attention to our limiting beliefs with, “A journey of 1,000 miles begins with a long, inward gaze.”

He quoted Daniel Pink that engagement requires the following three conditions to be present (104)

• Autonomy
• Mastery
• Purpose

He quotes Drucker that leaders should treat their workers as volunteers, because they are. It may seem unsettling, but our top talent walks out the door every day. What makes them want to return? He closes with the insight that people cannot be empowered, that the only genuine empowerment is self-empowerment, which he summarizes as “Proceed till apprehended.” He describes empowerment as a state of mind, not a job description.

This book reminded me of a scene in which a hospital CEO asked “How many people own a car?” followed by “How many of you have taken the car to a car wash?”

Then he asked, “How many of you have rented a car,” and “How many of you have taken the car to a car wash?” It took months before physicians came to the realization described in Collaborate for Success (page 5) that :

It has become abundantly clear that we have lost touch with each other. Forces are being brought to bear which many of us have ignored or dismissed because we have felt powerless to influence them. Our professional, ethical charge is to provide our services in the manner that is most beneficial to the welfare of our patients. We are now reminded that the hospital has the same responsibility. Our task is to work together to find solutions that will benefit all three- patient, physician, and hospital- and in so doing, gain strength from one another.”

At a meeting of his senior team, the CEO in All Hands on Deck said (114):

… the accountability pendulum has swung too far to the left brain. We’ve become so obsessed with counting beans that we forgot our future success depends upon planting beans. What had been a culture that encouraged entrepreneurial thinking gradually morphed into one which people were more concerned with covering their tracks than with blazing new trails….

They outlined 4 essential characteristics for building a culture of ownership:

• Commitment to values, vision, and the mission, as summarized by,“If you don’t stand for something, you’ll fall for anything.”
• Engagement with customers, co-workers, and the work itself, as summarized by,“There are no menial jobs, only menial attitudes.”
• Passion: Enthusiasm for the work and fellowship in the workplace, as summarized by, “Making sure that people are having fun is the ultimate retention strategy.”
• Pride in the organization, the job, and themselves, as summarized by, “The best way to make sure people are proud of their work is to assure competence and motivation through training, recommitting to have the best-trained people in the industry.”

What do you think?

As always, I welcome your input to improve collaboration in our workplaces.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

This month, I offer you a guest post, written by Lisa Shock, who works with physicians who are tired of treadmill medicine, i.e. working harder each year and making less money. If you are interested in transitioning, why not transition from a place of strength?

If you want to learn how this practice was able to optimize its operations and earn more money without working more hours, please read on.

Case Presentation

A physician who dreamed of delivering care to a rural NC community started his urgent-care business in 2006. He was open 7 days a week and with the help of one midlevel provider, delivered compassionate care to his local community. It was such a struggle to make payroll, he ultimately took on an external part time job when his own resources were spent. He contacted us in January 2009 uncertain of the future of his business.

He was desperate for ways to increase overall collections. Their payor mix had a large number of self-paying patients due to their urgent care hours. However, located in a rural small town of less than 15,000 residents, Medicare, Medicaid and third party payor reimbursement financed a majority of claims. Upon review of their collections and billing process, we found that they were losing money from denied claims, unpaid patient balances, and increasing accounts receivable. They had no experience with analysis of reports or internal research. They were relying on one staff member who preferred to work from home and they used a clearinghouse that did not send regular statements for collection of patient balances. In addition, their biller was not generating any monthly report data for review.

We focused on three basic areas: report generation, reconciliation of third party payor claims and collections, and patient collections. The intention was to improve overall collections through more efficient processes.

Methodology

The Model for Improvement Method was employed, using fundamental analysis and the Plan-Do-Study-Act (PDSA) cycle to make incremental changes within his practice.

The PDSA cycle tests change in the workplace. First a change is planned, then initiated and tried, then the results are observed. Permanent changes are implemented after learning what was successful. By testing small changes and evaluating the success of each test, results can be refined and broader changes may be implemented across a larger spectrum.

We designed several PDSA cycles to initiate change. First, we established a routine of running reports at defined times. We needed clearer information regarding patient balances and posted payments from third party payors, and we needed a system to view this information to accomplish an improved rate of collection within 60 days.

Next, we selected three items to track monthly within the report system:

1. CLAIMS POSTING – Many claims took an excess of 14 days to post to patient accounts. We decreased this delay time to no more than 3 business days.

2. DENIED CLAIMS – New procedures and updated clearinghouse software ensured that denied claims would be followed up within one workweek.

3. PATIENT BALANCES – Old patient balances lingered from 2007. We employed a collection agency and changed the front desk process such that patient balances are satisfied in full or a payment plan implemented before further services are rendered.

Results

Within one 30 day cycle, we improved total collections by 76.4% and over the 60-day target we improved collections by 47% overall. We achieved significant gains initially by collecting on patient accounts receivable within the last 30 days and refilling all denied claims within the last 60 days. The average collection ratio rose from 48 to 65.7% within that timeframe. The physician saw an average increase of $3000 per month and over the course of six months collected 16% more than the previous year. Average daily patient volume increased from 12-15 daily to 18-22.

For the first time, the physician understood payor mix, bad debt, and claims processing.

The physician initiated the transition from urgent to primary care and with this transition, negotiated improved reimbursement rates from third party payors. His staff met with state Medicaid officials to clarify billing processes, resubmitted Medicaid claims, and recovered nearly $2000 in claims outstanding.

The practice now utilizes a running calendar to follow with ongoing data report generation and claims analysis and a collection agency to settle bad debts. Unpaid claims from third party payors are reworked and refiled in a more timely fashion. Patient balances are reconciled and balances due are collected at the point of service. Now, if there is an issue with declining reimbursement, the practice can act more quickly to minimize impact on monthly cash flow.

Further review of their collections revealed that their overall collection rate was between 60% and 70% most months. This is significantly higher than average family practice rates of 50% and further reinforced that when they followed proper procedures, they achieved a measurable, sustainable improvement in cash flow.

The physician now has a framework that he applies to future data measurement to ensure improved collections. He is steadfast in his dream to deliver quality healthcare and now feels that he has a better chance of success as a result of improved measurement and more efficient processes.

Reference: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

Lisa P. Shock is the President/CEO of Utilization Solutions in Healthcare, Inc., a consulting firm specializing in teaching physicians how to get paid for the services that they provide and how to utilize PAs to their fullest potential. Please visit her website at www.pushpa.biz or contact her directly at lisa@pushpa.biz.

Kenneth H. Cohn, MD, MBA, FACS

© 2011, all rights reserved

Disclosure:

I have not received any compensation for writing this content. I have no material connection to the brands, topics and/or products that are mentioned herein.

Back in a previous century, faced with 20-minute car rides between hospitals where I worked in VT and NH, I invested in audiotapes from Nightingale Conant.  I selected negotiation because it was a topic about which I had no formal education.  The first technique that I remember Roger Dawson reviewing was “good cop- bad cop,” where one interviewer acts like a jerk and then a white knight appears to the rescue in whom one can “confide.”  I had recently walked away from a car salesman who had used this technique.

The next term I remember hearing was the “bogey,” where someone floats an innocent sounding question beginning with, “Just suppose…,” which I remember being used on me during a job interview after fellowship.  I listened with interest, thinking, “No wonder nobody wants us to know about this stuff!”  I recognized how many times before my ignorance was that of a lamb being led to slaughter.

When I was in business school, I took an elective on negotiation, where I learned about win-win negotiation, a major step up in the win-lose and lose-lose negotiations in which I had participated previously.  It was with no expectations that I opened up Steve Babitsky’s and Jim Mangraviti’s new book, Never Lose Again: Become a Top Negotiator by Asking the Right Questions.

First, I need to expand on the disclaimer below.  I teach at the SEAK Non-Clinical Careers for Physicians Seminar.  I have known Steve and Jim for 7 years, since I began taking SEAK courses as a student.  I have the utmost respect for them as teachers and entrepreneurs of integrity. 

Putting aside conflicts of interest , this is a great book.  Reading it is pure, painless growth.  I loved the way each chapter began with a field-tested, practical question that one can use in a negotiation, followed by dialogue on the question to the point of sale.  The ending is equally clever, with suggestions on what to do when the roles reverse and you are asked the question.  My favorite 5 (of 50) questions were:

• So, how did you hear about us; a great way to probe for information at the beginning of a negotiation
• What is your time frame for wrapping up this negotiation; allows one to find out about time pressures
• Can you shoot me an e-mail before our meeting with your issues, goals, and concerns, so that I can prepare
• How about we try it for a while; what do we have to lose
• Will you give us a best-price guarantee

I think that every physician should read this book.  I just wish that medical schools and residency program directors would make it required reading.

Kenneth H. Cohn, MD, MBA, FACS

© 2011, all rights reserved

 Disclosure:

I have a material connection because I received a review copy that I can keep for consideration in preparing to write this content.